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					CIGNA HealthCare                   Introduction & Important Information
Physician & Health Care
Practitioner Reference Guide




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CIGNA HealthCare                                                                                            Table of Contents
Physician & Health Care                                                                             Table of Contents
Practitioner Reference Guide


Table of Contents
Introduction and Important Information ......................................................................8
  In This Section .......................................................................................................................... 8
  How to Contact Us .................................................................................................................... 9
  Provider Information and Directories....................................................................................... 10
  National Provider Identifiers .................................................................................................... 10
  CIGNA HealthCare Benefit Designs and Plan Features ......................................................... 11
  CIGNA Choice FundSM ............................................................................................................ 12
     What You Need to Know ..................................................................................................... 12
  Quick Guide to CIGNA HealthCare ID Cards.......................................................................... 12
  Marketing Affiliations ............................................................................................................... 12
  Shared Administration............................................................................................................. 13
  Participating Service Areas ..................................................................................................... 13
  State-Specific Information ....................................................................................................... 15
     New Jersey.......................................................................................................................... 15
     New York ............................................................................................................................. 17
     Connecticut.......................................................................................................................... 28
     Pennsylvania ....................................................................................................................... 29
  Patient Consent Form ............................................................................................................. 37
  The Importance of Well Care Visits......................................................................................... 39
     What Is a Well Care Visit?................................................................................................... 39
     Acceptable Codes For Well Care Visits............................................................................... 39
  Local Specialty Networks ........................................................................................................ 39
     Home Health Services......................................................................................................... 39
        CareCentrix...................................................................................................................... 39
        Apria................................................................................................................................. 40
     Chiropractic Services........................................................................................................... 40
        American Specialty Health Networks (ASHN) ................................................................. 40
     Physical and Occupational Therapy .................................................................................... 40
        OrthoNet .......................................................................................................................... 40
     Rehabilitation Provider Network (RPN) ............................................................................... 41



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Physician & Health Care
Practitioner Reference Guide

      Laboratory Services............................................................................................................. 41
         Quest Diagnostics............................................................................................................ 41
      Radiology Services.............................................................................................................. 42
         American Imaging Management (AIM) ............................................................................ 42
         AIM Web-Based Services ................................................................................................ 43
         In-Office Imaging Privileges for Non-Radiologists ........................................................... 43
         MedSolutions, Inc. ........................................................................................................... 44
      Vision Care .......................................................................................................................... 44
         Vision Service Plan (VSP) ............................................................................................... 44

Provider Participation ........................................................................................................... 45
   Primary Care Physician (PCP) Services ................................................................................. 45
   Specialty Care Physician (SCP) Services............................................................................... 45
   Service Standards and Requirements .................................................................................... 46
      Acceptance and Transfer of Members ................................................................................ 46
      Closing a Panel ................................................................................................................... 46
      Member Removal from a PCP Panel .................................................................................. 46
         Communication to Members of Provider Termination...................................................... 47
      Office Hours and Accessibility ............................................................................................. 47
      Appointments and Scheduling Guidelines........................................................................... 48
      Professional Services .......................................................................................................... 48
      Cooperation with Programs ................................................................................................. 48
      Member Billing..................................................................................................................... 48
   Confidentiality.......................................................................................................................... 49
      Medical Record Reviews ..................................................................................................... 49
         Medical Record Documentation....................................................................................... 49
      Ambulatory Medical Record Review (AMRR)...................................................................... 50
   Performance Evaluation.......................................................................................................... 51

Credentialing........................................................................................................................... 52
   Council for Affordable Quality Healthcare (CAQH) Credentialing Database System.............. 52
      Submitting Paper Forms...................................................................................................... 52
      Credentialing Criteria Verified Through Office Site Visit...................................................... 54




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CIGNA HealthCare                                                                                             Table of Contents
Physician & Health Care
Practitioner Reference Guide

     Notice of Material Changes ................................................................................................. 54
     Termination Appeal Process ............................................................................................... 54
     Recredentialing Process...................................................................................................... 55
     Non-Physician Practitioners ................................................................................................ 56

Claims and Compensation .................................................................................................. 57
  Claim Submission ................................................................................................................... 57
     Paper Claim Submission ..................................................................................................... 57
     Definition of a Complete Claim ............................................................................................ 58
  Supplemental Claim Information ............................................................................................. 59
     Claim Filing Deadline........................................................................................................... 60
     Claim Inquiry and Follow-Up ............................................................................................... 61
     Payment Policies ................................................................................................................. 61
     Surgical Assistant Modifiers ................................................................................................ 61
        Multiple Surgery Policy .................................................................................................... 62
        Tips .................................................................................................................................. 62
     Immunization Policy............................................................................................................. 62
     ClaimCheck® ....................................................................................................................... 63
  Member Liability Collection Guidelines ................................................................................... 63
     Coordination of Benefits ...................................................................................................... 63
     CIGNA as Primary Payer..................................................................................................... 64
     CIGNA as Secondary Payer................................................................................................ 64
     Order of Benefit Determination............................................................................................ 64
        Determining Primacy on a Participant/Spouse ................................................................ 64
        Determining Primacy on a Dependent Child.................................................................... 64
        Determining Primacy with Medicare ................................................................................ 65
     Workers’ Compensation ...................................................................................................... 65
     Subrogation/Reimbursement Requirements ....................................................................... 65
  Payment Recovery.................................................................................................................. 66
  Explanation of Payment .......................................................................................................... 66
     Posting Payments and Adjustments.................................................................................... 66
     Health Care Fraud ............................................................................................................... 66




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CIGNA HealthCare                                                                                           Table of Contents
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Electronic Services ............................................................................................................... 67
   Quick Summary of Key Tools.................................................................................................. 67
   CIGNA for Health Care Professionals Website....................................................................... 68
   Electronic Data Interchange.................................................................................................... 69
      Electronic Claims Submission ............................................................................................. 69
      Electronic Remittance Advice.............................................................................................. 69
      Interactive Electronic Data Interchange Transactions ......................................................... 69
   Electronic Transaction Support Options.................................................................................. 70
      Post-N-Track ....................................................................................................................... 70
      Clearinghouses.................................................................................................................... 70
   1.800.88CIGNA (882.4462) .................................................................................................... 71
   Electronic Funds Transfer (Direct Deposit) ............................................................................. 72
      Direct Deposit Enrollment Instructions ................................................................................ 72

Medical/Utilization Management ........................................................................................ 74
   Medical Management Models ................................................................................................. 74
      Personal Health Solutions (PHS) ........................................................................................ 75
   Precertification ........................................................................................................................ 75
      Precertification Protocol....................................................................................................... 76
      Emergency Services............................................................................................................ 77
      Maternity/Obstetric Admissions ........................................................................................... 77
      Outpatient Precertification List............................................................................................. 77
      CPT Codes and HCPCS Codes Requiring Precertification................................................. 78
   Physician Office Laboratory Tests .......................................................................................... 78
   Inpatient Case Management/Continued Stay Review............................................................. 78
      Case Management .............................................................................................................. 79
      Total Joint Recovery Program ............................................................................................. 80
      Referral Guidelines.............................................................................................................. 80
      Referral Process.................................................................................................................. 81
         Exceptions To Referral Process ...................................................................................... 81
         Open Access, Open Access Plus and PPO..................................................................... 82
         Obstetric and Gynecology (OB/GYN) Care ..................................................................... 82
         Mental Health and Substance Abuse Program................................................................ 82



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         Vision Care ...................................................................................................................... 82
   CIGNA Well Aware for Better HealthSM ................................................................................... 82

Quality Management ............................................................................................................. 84
   Clinical Care Guidelines.......................................................................................................... 84
   Peer Review............................................................................................................................ 85
   Medical and Behavioral Continuity and Coordination of Care................................................. 85
   Pharmacy and Therapeutics Review ...................................................................................... 86
   Clinical and Quality Improvement Studies .............................................................................. 86
   Provider Excellence Recognition Directory ............................................................................. 86
   Health Plan Employer Data and Information Set (HEDIS®) .................................................... 87
      HEDIS Medical Record Review........................................................................................... 87
      2006 HEDIS® Measures for 2005 Data ............................................................................... 88
      New 2006 HEDIS® Measures.............................................................................................. 96

Prescription Drug Program ................................................................................................. 98
   Plan Options............................................................................................................................ 98
   Prescription Drug List.............................................................................................................. 99
      Medications Requiring Precertification ................................................................................ 99
      Medications Typically Excluded from the Prescription Benefit .......................................... 101
      Prescriptions more than one year after the original date of issue. .................................... 102
      CIGNA Tel-Drug One Touch ............................................................................................. 103
   Specialty Pharmacy Prescription Drug Program................................................................... 103
      Preferred Specialty Pharmaceutical List............................................................................ 103
      Specialty Pharmacy Orders............................................................................................... 104
         New Orders.................................................................................................................... 104
         Transfers........................................................................................................................ 104
      Change in Coverage for Self-administered Injectable Medications................................... 105

Specialty Networks .............................................................................................................. 107
   CIGNA LIFESOURCE Transplant Network® ......................................................................... 107
   CIGNA Behavioral Health ..................................................................................................... 107




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Dispute Resolution .............................................................................................................. 108
   Provider Payment Appeals.................................................................................................... 108
      First-Level Review ............................................................................................................. 108
      Second-Level Review........................................................................................................ 108
      Additional Payment Appeal Options .................................................................................. 109
   Provider Termination Appeals............................................................................................... 109
      Second-Level Review........................................................................................................ 109
   Arbitration.............................................................................................................................. 110

Member Information ............................................................................................................ 111
   Replacement of Social Security Number by Alternate Member Identifier ............................. 111
      Verification Options ........................................................................................................... 112
   Member Rights and Responsibilities..................................................................................... 112
   Member Concern or Complaint ............................................................................................. 113
      Provider Cooperation......................................................................................................... 114
   Health Insurance Portability and Accountability Act (HIPAA) of 1996................................... 114
      Security Regulations.......................................................................................................... 114




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CIGNA HealthCare                                                         Introduction and
                                                                   Introduction & Important Information
Physician & Health Care                                                     Important Information
Practitioner Reference Guide




Introduction and Important Information
You work hard to deliver quality health care services. To assist you, we prepared this
comprehensive Reference Guide containing important information about the CIGNA HealthCare
Program Requirements/Administrative Guidelines − the rules and procedures pertaining to our
programs.
CIGNA HealthCare is committed to working with physicians, hospitals and employers to give our
members access to quality services and benefits. Your cooperation and compliance with the
procedures outlined in this guide will benefit you and your patients. Our Program
Requirements/Administrative Guidelines are updated periodically. We will give you advance
notice of material changes to our Program Requirements/Administrative Guidelines.
We welcome your feedback and measure and track our performance through annual provider
surveys. Feel free to contact us at any time if you have questions about the information in this
guide or the administration of our plans and programs. Your CIGNA HealthCare Provider
Services Department is dedicated to serving you and is available to discuss network and
participation matters, resolve problems and provide assistance and training to you and your
staff.
Thank you for your care and commitment to our members.

In This Section
In this section, you will find information on:
• How to Contact Us
• CIGNA HealthCare Plans
• State-Specific Information

All references to “providers” in this guide will mean participating hospitals, ancillary facilities and
other health care professionals as applicable. If there is a conflict between this reference guide
and your provider agreement with CIGNA HealthCare or applicable law, the terms of your
agreement or the applicable law will supersede this guide.
CIGNA” or “CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are
provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance
Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries
of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of
Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. In Virginia, HMO plans are offered by
CIGNA HealthCare of Virginia, Inc. and CIGNA HealthCare Mid-Atlantic, Inc. In North Carolina, HMO plans are offered by
CIGNA HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by Connecticut
General Life Insurance Company.




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How to Contact Us
While this reference guide gives you important procedural requirements, at times you may need
to contact us.
 Service/Source                         Information Available
                                        • Access online information on patient eligibility,
                                          benefits, and claim status
                                        • Request fee schedule information
 The CIGNA for Health Care              • View information about claim coding policies and
 Professionals website                    payment guidelines
 www.cignaforhcp.com                    • E-mail questions about patient benefits
                                        • Review our medical or pharmacy coverage
                                          positions
                                        • View the pharmacy formulary
                                        • Obtain patient information such as eligibility,
                                          benefits, and claim status
                                        • Request precertification
                                        • Check credentialing status
 1.800.88CIGNA (882.4462)               • Learn about our electronic services
                                        • Check the status of an appeal
                                        • Request an exception to the Prescription Drug
                                          List
                                        • Speak with a customer service representative
                                          8 a.m. to 6 p.m.
 1.800.TELDRUG (835.3784) or visit      Place an order through or ask a question of CIGNA
 www.teldrug.com                        Tel-Drug
                                        Contact a CIGNA LIFESOURCE Transplant
 1.800.668.9682 or visit
                                        Network® case manager or obtain information about
 www.cigna.com/lifesource
                                        our organ and tissue transplant network
                                        • Call Member Services 8 a.m. to 5 p.m.
                                        • Obtain other telephone numbers and addresses
 The back of the CIGNA HealthCare
                                        • Submit a paper claim or appeal
 member ID card
                                        • Contact CIGNA Behavioral Health
                                        • Call CIGNA HealthCare Customer Service




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Provider Information and Directories
The provider services team maintains information on participating providers in the CIGNA
HealthCare provider database. This information is used to publish provider directories, send
communications to providers and pay claims. Notify us in writing 90 days before a change
occurs that affects members, the directory or the claim payment process. Examples of such
changes include changes in address, telephone number, tax identification number, specialties
or the closing or opening of locations.
It is essential you are consistent when identifying yourself in written communications and claim
submissions. Using abbreviations, variations of names, provider licensure, or tax identification
numbers not listed in a provider agreement may result in delayed changes to the provider
directories and incorrect claim payments. The latest provider directory is available at
www.cigna.com.
There are several ways to submit demographic changes to CIGNA HealthCare. You can submit
changes electronically using the online form available at www.cignaforhcp.com. Alternatively,
you can submit a paper copy of the form. Here is the link to the form −
https://pss.healthcare.cigna.com/healthcare/provider/app/prot/req/pdselectform.do. You must be
a registered user of our website to access this form online.

National Provider Identifiers
The Centers for Medicare and Medicaid services have issued final rules for HIPAA’s National
Provider Identifier (NPI). The rules require the NPI to be used to identify providers on standard
electronic transactions, but permit the NPI to be used for any other lawful purpose.
This unique identifier will be used for submitting and processing the HIPAA standard electronic
transactions beginning no later than May 23, 2007.
The Centers for Medicare and Medicaid Services make information on the NPI available on their
website at www.cms.hhs.gov/hipaa/hipaa2/regulations/identifiers/default.asp. As the effective
date approaches, look for additional information at www.cignaforhcp.com.




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CIGNA HealthCare                                                                               Introduction & Important Information
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CIGNA HealthCare Benefit Designs and Plan Features
The following benefit plan guide provides a summary of CIGNA HealthCare benefit plans.
Benefit Plan Guide




*For POS and POS Open Access Products − Plans offered through CIGNA HealthCare of ____, Inc. are HMO plans; Plans offered through
Connecticut General Life Insurance Company are Network plans.


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CIGNA Choice FundSM
CIGNA HealthCare offers two CIGNA Choice FundSM options − a Choice Fund Health
Reimbursement Arrangement (HRA) and a Choice Fund Health Savings Account (HSA). CIGNA
Choice Fund packages a consumer health care fund with an underlying Preferred Provider
Organization (PPO) or Open Access Plus (OAP) medical plan.
Your claim will be processed and if funds are available in the HRA or HSA account, you may be
reimbursed directly for coinsurance and deductibles, reducing your need to collect from the patient

What You Need to Know
• For these patients, Choice Fund appears on the front of the member identification card.
• As with all other CIGNA HealthCare plans with deductibles and coinsurance, do not collect
  deductibles or coinsurance at the time of service. (These plans generally do not have
  copayments.)
• Your Explanation of Payment (EOP) will show the member responsibility due, if any. If funds
  are available in the HRA or HSA, you will receive an EOP from the medical plan and one
  from the HRA or HSA. Remark codes clearly identify that the claim was forwarded to the
  HRA or HSA for payment.
• Under standard benefit plans, allowable preventive care services are reimbursed at 100%,
  with no copayment, coinsurance or deductible.

For more information, visit our website at
http://www.cigna.com/health/consumer/medical/ccf.html or call 1.800.88CIGNA (882.4462).

Quick Guide to CIGNA HealthCare ID Cards
Access the Quick Guide to CIGNA HealthCare ID cards through this link
http://www.cigna.com/health/provider/medical/member_id_cards.pdf.

Marketing Affiliations
Some of your patients may participate with CIGNA HealthCare through a marketing affiliation.
This means CIGNA HealthCare and the affiliation plan jointly market in a select geographic
area. Patients in these plans can access care through the affiliation plan’s network of
participating providers in that select geographic area. In all other locations, patients access care
through the CIGNA HealthCare network.
Refer to the ID card to determine how to verify eligibility, obtain precertification and submit
claims for these patients.




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Shared Administration
CIGNA HealthCare sometimes works with clients who may use a third party to provide certain
services such as claim processing, utilization management or eligibility verification that CIGNA
HealthCare usually performs for its other clients. In these situations, the CIGNA HealthCare ID
card may include the third party’s name and will tell you how to verify eligibility, obtain
precertification and submit claims. Claims will be processed according to your contracted rates.

Participating Service Areas
CIGNA HealthCare of Connecticut service area includes the following counties:
• Fairfield                                         • Hartford
• Litchfield                                        • Middlesex
• New Haven                                         • New London
• Tolland                                           • Windham
CIGNA HealthCare of Delaware service area includes the following counties:
• Kent                            • Delaware                         • Franklin
• Bucks                           • Carbon                           • Perry
• Adams                           • Mifflin                          • Juniata
• Lehigh                          • Montgomery                       • Schuylkill
• New Castle                      • Cumberland                       • Lancaster
• Chester                         • Monroe                           • York
• Berks                           • Philadelphia counties            • Lebanon
• Luzerne                         • Dauphin
• Sussex counties                 • Northampton

The Delaware Valley Region consists of three areas – Delaware (the state), Southeastern
Pennsylvania, and Central Pennsylvania.

CIGNA HealthCare of New Jersey service area includes the following counties:

• Bergen                          • Mercer                           • Cape May
• Morris                          • Hudson                           • Salem
• Atlantic                        • Somerset                         • Middlesex
• Gloucester                      • Camden                           • Union
• Essex                           • Ocean                            • Cumberland
• Passaic                         • Hunterdon                        • Monmouth
• Burlington                      • Sussex                           • Warren



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CIGNA HealthCare                                   Introduction & Important Information
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Practitioner Reference Guide

CIGNA HealthCare of New York service area includes the following counties:

• Bronx                          • Orange                          • Suffolk
• New York (Manhattan)           • Rockland                        • Nassau
• Richmond (Staten               • Westchester                     • Queens
  Island)                        • Kings County                    • Sullivan
• Ulster                           (Brooklyn)
• Dutchess                       • Putnam

CIGNA HealthCare of New York (Syracuse) service area includes the following counties:

• Cayuga                         • Oswego                          • Onondaga
• Herkimer                       • Cortland
• Oneida                         • Madison
CIGNA HealthCare of New York, Inc. participating service areas (markets):

Commercial HMO Service Area Counties

• Bronx                          • Orange                          • Staten Island
• Brooklyn (Kings)               • Putnam                            (Richmond)

• Manhattan (New York)           • Queens                          • Suffolk

• Nassau                         • Rockland                        • Westchester

Managed Care Service Area Counties:

• Bronx                          • Nassau                          • Rockland
• Brooklyn (Kings)               • Oneida                          • Staten Island
• Cayuga                         • Onondaga                          (Richmond)

• Cortland                       • Orange                          • Suffolk

• Dutchess                       • Oswego                          • Westchester

• Madison                        • Putnam
• Manhattan (New York)           • Queens

PPO Service Area Counties

• Albany                         • Cayuga                          • Dutchess
• Allegheny                      • Chautaugua                      • Erie
• Bronx                          • Chemung                         • Franklin
• Brooklyn (Kings)               • Chenango                        • Fulton
• Broome                         • Columbia                        • Genesse
• Cattaraugus                    • Cortland                        • Greene



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CIGNA HealthCare                                      Introduction & Important Information
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• Herkimer                         • Ontario                               (Richmond)
• Jefferson                        • Orange                            • Steuben
• Livingston                       • Oswego                            • Suffolk
• Madison                          • Otsego                            • Sullivan
• Manhattan (New York)             • Putnam                            • Tompkins
• Monroe                           • Queens                            • Ulster
• Montgomery                       • Rensselaer                        • Warren
• Nassau                           • Rockland                          • Washington
• Niagra                           • Saratoga                          • Wayne
• Oneida                           • Schenectady                       • Westchester
• Onondaga                         • Staten Island                     • Wyoming

State-Specific Information
In some areas, state law supersedes standard policies and procedures outlined in this guide.
The following state-specific information is provided for your reference. Note that these state law
requirements only apply to the extent required by applicable law and do not apply to participants
covered under self-funded plans.

New Jersey
    Subrogation/Worker’s Compensation

    Subrogation and third party recovery provisions are prohibited.

    Posting payments

    Explanation of benefits (EOB) and explanation of payments (EOP) have been revised to
    include plan language and specific reasons for denials; not just the denial code. In addition,
    the EOB has been revised as follows: if you are covered by more than one health benefit
    plan, you should file all of your claims with each plan and provide each plan with information
    regarding the other plans under which you are covered.

    Service Standards

    Urgent case should have access to appointments within 24 hours of member’s phone call.

    Order of Benefit Determination

    When the primary plan is not subject or compliant with New Jersey regulations, the
    secondary plan must attempt to (i) secure all information needed to correctly determine its
    liability or (ii) assume the primary position if the non complying plan is unwilling to act as
    primary or does into supply the needed information. Please note New Jersey has specific
    procedures for secondary plans/managed care coordination.




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    Retiree Rule --The retiree rule for the state of New Jersey should be used when
    determining coverage for laid off or retired employees. Maintenance of Benefits (MOB), Non
    duplication of Benefits (Non Dup) and Super 65 options are not permitted

    Dispute Resolution for New Jersey

    1. To resolve disputes relating to the payment of provider claims under Health Benefit Plans
        as defined in N.J.A.C. 11:22-1.2, but not including appeals made pursuant to N.J.A.C.
        8:38-8.5 through 8.7 and 8:38A-3.6 and 3.7 (utilization management):

       In the event that Provider has a dispute with respect to a claim, the dispute shall be
       submitted for review and resolution to the CIGNA designee identified by CIGNA in
       CIGNA's explanation of payment, or by calling 1.800.CIGNA24. Provider must submit a
       written request for a review of a claim dispute within 180 days of the date of the initial
       explanation of payment. Provider must submit a written explanation of the dispute,
       including a copy of the disputed claim, the explanation of payment, and documentation
       substantiating the appeal. The internal review shall be conducted and its results
       communicated in a written decision to Provider within 10 business days of the receipt of
       the appeal. The written decision shall include:

       (i) The names, titles and qualifying credentials of the persons participating in the
           internal review;

       (ii) A statement of Provider’s grievance;

       (iii) The decision of the reviewers along with a detailed explanation of the contractual
             and/or medical basis for such decision;

       (iv) A description of the evidence or documentation which supports the decision; and

       (v) If the decision is adverse, notice of the right to have the decision submitted to
           arbitration pursuant to the arbitration process set forth in the Dispute Resolution
           section of this Physician and Health Care Practitioner Reference Guide. Provider
           shall not be required to request a second level review prior to initiating arbitration.

       Provider must submit a request for arbitration within 12 months of the date of the letter
       communicating the adverse appeal decision. The decision of the arbitrator shall be
       issued no later than 30 business days from receipt by the arbitrator of all documentation
       necessary to complete the review.

    2. To resolve disputes with respect to a termination and for claim disputes with respect to
       ASO Participants, but not including appeals made pursuant to N.J.A.C. 8:38-8.5 through
       8.7 and 8:38A-3.6 and 3.7 (utilization management):

       In the event that Provider has a dispute with respect to a claim or a termination, the
       dispute shall be submitted for review and resolution to the CIGNA designee identified by
       CIGNA in CIGNA's explanation of payment or termination letter, as applicable (the "First
       Level Review"). Provider must submit a request for a First Level Review of a payment
       dispute within 180 days of the date of the initial explanation of payment and a request for




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         a First Level Review of a termination dispute within 30 days of the date of the
         termination letter. If Provider is not satisfied with the resolution at the First Level
         Review, Provider may submit the matter for a second level review to the CIGNA
         designee identified in the First Level Review decision letter (the "Second Level Review").
         Provider must submit a request for a Second Level Review within 60 days of the date of
         the letter communicating the First Level Review decision. The Second Level Review
         decision will be binding on CIGNA and Provider if the resolution is accepted by Provider.

         If the Second Level Review is adverse, Provider may have the decision submitted to
         arbitration pursuant to the arbitration process set forth in the Dispute Resolution section
         of this Physician and Health Care Practitioner Reference Guide. Provider must submit a
         request for arbitration within 12 months of the date of the letter communicating the
         Second Level Review decision.

    3. Arbitration of All Disputes

          Disputes regarding a claim or a termination that are not resolved through the process
          described in items 1. and 2. above and any other dispute between the parties regarding
          the performance or interpretation of the provider agreement shall be resolved by
          arbitration between the parties. The arbitration process is set forth in the Dispute
          Resolution section of this Physician and Health Care Practitioner Reference Guide.
          Either party may initiate arbitration by providing written notice to the other party. If
          Provider initiates arbitration, Provider must submit a request for arbitration to:

          CIGNA HealthCare
          National Appeals Unit
          P.O. Box 37963
          Charlotte, NC 28237

    4.    If Provider fails to request a review or arbitration of Provider’s payment or termination
          dispute within the applicable timeframes in items 1. 2., and 3. above, CIGNA’s last
          determination regarding the dispute shall be binding on Provider. Provider shall not bill
          the Participant for payments that are denied on the basis that Provider failed to submit
          the request for review or arbitration within the required timeframes.

    5.    In addition to the above, for disputes concerning the application of CIGNA's coding and
          payment rules and methodologies to patient specific factual situations, Provider should
          consult CIGNA's website for details regarding a billing dispute resolution process that
          may be applicable and that Provider may be entitled to elect in lieu of arbitration.

New York
    Provider Payment Appeals

    The utilization review appeal procedures available to members may be available for certain
    post service medical necessity denials.




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    Provider information and directories

    Demographic information sent to CIGNA HealthCare should also be consistent with the
    providers’ information posted in the New York Department of Education database and the
    New York Department of Health “Health Provider Network” (HPN) database.

    Utilization Review

    Maternity stay services include parent education, assistance and training in breast or bottle
    feeding, and the performance of any necessary maternal and newborn clinical
    assessments.

   Member Rights and Responsibilities
   Change of Primary Care Physician (PCP)
    A member who is dissatisfied with the assigned or selected PCP shall be allowed to select
   another but not more than once in any calendar month. If the member selects a new PCP
   before the fifteenth day of the month, the designation will be effective on the first day of the
   month following his/her selection. If the member selects a new PCP on or after the fifteenth
   day of the month, the designation will be effective on the first day of the month following the
   next full month
   Member Liability Collection Guidelines
   For uncovered services, provider must advise enrollee, prior to initiating of service, that the
   services are uncovered and the cost of the service.
   Dispute Resolution
   If a provider’s license, certification or registration is revoked or suspended, by the State, the
   provider will be terminated from the HMO network.
   Referral Process
   Exceptions to Referral Process
   A new Member whose health care provider is not a member of the Healthplan’s network and
   who is (i) are receiving an on-going course of treatment for a life-threatening disease or
   condition, or a degenerative or disabling disease or condition, or (ii) has entered the second
   trimester of pregnancy as of the effective date of enrollment may be eligible to receive
   continuity of care from that non-participating provider for a transitional period of up to sixty
   (60) days, or the post partum period directly related to the delivery of the child . Such
   continuity of care must be approved in advance by CIGNA and the non-participating doctor
   must agree to accept CIGNA's reimbursement rate and to abide by CIGNA policies and
   procedures and quality assurance requirements
   General Guidelines
   •   Referral to a provider outside of the plan’s network may be requested when a network
       does not include an available provider with the appropriate training and experience to
       meet the needs of the members. The referral should be made pursuant to an approved
       treatment plan by the MCO, PCP and non participating provider. The enrollee may not
       elect to use a non participating specialist unless there is no specialist in the network.



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   •   Extended referral to a specialty care provider may be requested for a condition which
       requires ongoing care from a specialist. The PCP should contact CIGNA to discuss the
       Medical Necessity of the extended referral and to arrange for the authorization.”
   Precertification
   Emergency Services
   An emergency medical condition is defined as a medical or behavioral condition, the onset
   of which is sudden, that manifests itself by symptoms of sufficient severity, including pain,
   that a prudent layperson, possessing an average knowledge of medicine and health, could
   reasonably expect the absence of immediate medical attention to result in: (a) placing the
   health of the person afflicted with such condition in serious jeopardy, or in the case of a
   behavioral condition, placing the health of such person or others in serious jeopardy; or (b)
   serious impairment to such person’s bodily functions; or (c) serious dysfunction of any bodily
   organ or part of such person; or (d) serious disfigurement of such person.
   Specialized Care Over a Prolonged Period of Time
   Extended referral to a specialty care provider may be requested for a condition which
   requires ongoing care from a specialist. The PCP should contact CIGNA to discuss the
   Medical Necessity of the extended referral and to arrange for the authorization.
    For a life-threatening condition or disease, a degenerative and disabling condition or
    disease, or a condition which requires specialized medical care over a prolonged period of
    time, a specialty care provider may be designated as the member’s coordinating care
    provider or be referred to a specialty care center for treatment. The PCP should contact
    CIGNA to determine the Medical Necessity of the situation and to arrange for
    authorization.”

    New York Public Health Law Article 49 Utilization Review Provisions

    Determination regarding services and treatment will be communicated within the following
    time frames:
        • All determinations of medical necessity will occur within three (3) business days of
            receiving all necessary clinical information. Notice of this determination will be
            given to member and provider by telephone with a written follow-up.
        • Determination as to whether your hospital stay needs to be extended happens on
            the day that all necessary clinical information has been received. Notice of this
            determination will be given to provider by telephone with written follow-up.
        • Decisions related to the medical necessity of services that have already been
            received will be made within thirty (30) days after receiving the necessary
            information.
    Decisions regarding situations such as a request for continued or extended services,
    procedures or treatments; or a request for additional services to an existing course of
    treatment will be made within two (2) business days.

    Denials will be rendered by qualified clinical peer reviewers. Denial letters will explain the
    reason for the decision and details on how to proceed through the Appeals Process, and
    note that clinical review criteria relied upon to make the decision are available upon request
    and what if any additional necessary information must be provided to render a decision on
    appeal.



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    “The provider may request reconsideration of a denial. This reconsideration will occur
    within one (1) business day of the receipt of the request, if the provider was not involved in
    the denial process.
    “If services are denied, or if decisions are not rendered within the time frames described
    above, the member or member’s designee may initiate the Appeals Process

    New York Public Health Law Article 49 Utilization Review Appeal Provisions
    The following utilization review appeal provisions are available to members and their
    designees, and to providers for certain post-service adverse determination, under New
    York Public Health Law Article 49. These provisions are as described in member service
    agreements.


    Appeals of Utilization Review Decisions
    The Healthplan has a two-step appeals procedure to review any dispute you may have
    regarding a Healthplan utilization review determination. To initiate an appeal, you must
    submit a request for an appeal in writing at the address shown above within 365 days of
    receipt of a denial notice. You should state the reason why you feel your appeal should be
    approved, and include any information supporting your appeal. If you are unable or choose
    not to write, you may ask to register your appeal or ask for information about utilization
    review decisions by calling the toll-free number on your CIGNA HealthCare ID card or
    Benefit Identification card, Monday through Friday, during regular business hours. If calling
    after hours, please follow the recorded instructions if you wish to leave a message.
    We will acknowledge your appeal in writing within five (5) business days after we receive
    the appeal. Acknowledgments include the name, address, and telephone number of the
    individual designated to respond to the appeal, and indicate what additional information, if
    any, must be provided.
    If no decision is made within the applicable time frames described below regarding your
    appeal of an adverse utilization review determination, the adverse determination will be
    deemed to be reversed.
    Level One Appeal (“Final Adverse Determination”)
    You or your representative (with your acknowledgement and consent) must submit your
    Level One appeal in writing or by phone to:
                                      [the healthplan Name]
                                    [the healthplan Address]
     [Customer Services Toll-Free Number that appears on your CIGNA HealthCare ID card or
                                   Benefit Identification card]
    Your appeal will be reviewed and the decision made by someone not involved in the initial
    decision. Appeals involving Medical Necessity or clinical appropriateness will be
    considered by a health care professional of the same or similar specialty as the care under
    consideration.




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    We will respond in writing with a decision within fifteen (15) calendar days after we receive
    an appeal. If more information is needed to make the determination, we will notify you in
    writing to request an extension of up to fifteen (15) calendar days and to specify any
    additional information needed to complete the review. You are not obligated to grant us an
    extension, or to provide the requested information.
    You may request that the appeal process be expedited if, (a) the time frames under this
    process would seriously jeopardize your life, health or ability to regain maximum
    functionality or, in the opinion of your Physician, would cause you severe pain, which
    cannot be managed without the requested services; or (b) your appeal involves non-
    authorization of an admission or continuing inpatient hospital stay; or (c) your appeal
    involves (1) continued or extended health care services, procedures or treatments or
    additional services for an insured undergoing a course of continued treatment prescribed
    by a health care provider or (2) an adverse determination in which the health care provider
    believes an immediate appeal is warranted except any retrospective determination.
    When an expedited appeal is requested, Healthplan will provide reasonable access to its
    clinical peer reviewer within one (1) business day after receiving the appeal. When an
    appeal is expedited, we will respond verbally with a decision within two (2) business days
    after receiving all the necessary information, but in no event later than 72 hours after
    receiving the appeal. A written notice of the decision will be transmitted within two (2)
    business days after rendering the decision. If you are not satisfied with the result of the
    expedited appeal review, you may further appeal under the time frames above, or through
    the external appeal process described below.
    If you remain dissatisfied with the Level One or Expedited Appeal decision of the
    Healthplan, you have the right to request an External Appeal, as well as a Level Two
    Appeal as described below. You may also request an External Appeal application from the
    New York Insurance Department toll-free at (800) 400-8882, or its website
    (www.ins.stat.ny.us); or the New York State Department of Health at (518) 486-6074 or its
    website (www.health.stat.us).
    Level Two Appeal
    If you are dissatisfied with our level one appeal decision, you may request a second review.
    To initiate a level two appeal, follow the same process required for a level one appeal.
    Most requests for a second review will be conducted by the Appeals Committee, which
    consists of a minimum of three people. Anyone involved in the prior decision may not vote
    on the Appeals Committee. For appeals involving Medical Necessity or clinical
    appropriateness, the Committee will consult with at least one Physician in the same or
    similar specialty as the care under consideration, as determined by the Healthplan Medical
    Director. You may present your situation to the Committee in person or by conference call.
    For level two appeals, we will acknowledge in writing that we have received your request
    and schedule a Committee review. For pre-service and concurrent care coverage
    determinations, the Committee review will be completed within fifteen (15) calendar days
    and for post-service claims, the Committee review will be completed within thirty (30)
    calendar days. If more information is needed to make the determination, we will notify you
    in writing to request an extension of up to fifteen (15) calendar days and to specify any
    additional information needed by the Appeal Committee to complete the review. You are
    not obligated to grant us an extension, or to provide the requested information.




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    You will be notified in writing of the Appeal Committee's decision within five (5) business
    days after the committee meeting, and within the committee review time frames above if
    the Appeal Committee does not approve the requested coverage.
    You may request that the appeal process be expedited if, (a) the time frames under this
    process would seriously jeopardize your life, health or ability to regain maximum
    functionality or, in the opinion of your Physician, would cause you severe pain, which
    cannot be managed without the requested services; or (b) your appeal involves non-
    authorization of an admission or continuing inpatient hospital stay or (c) your appeal
    involves (1) continued or extended health care services, procedures or treatments or
    additional services for an insured undergoing a course of continued treatment prescribed
    by a health care provider or (2) an adverse determination in which the health care provider
    believes an immediate appeal is warranted except any retrospective determination. The
    Healthplan Medical Director, in consultation with the treating Physician, will decide if an
    expedited appeal is necessary. When an appeal is expedited, we will respond verbally with
    a decision within seventy-two (72) hours, followed up in writing.
    External Appeal
    1.    Your right to an external appeal
          Under certain circumstances, you have a right to an external appeal of a denial of
          coverage. Specifically, if the Healthplan has denied coverage on the basis that the
          service is not Medically Necessary or is an experimental or investigational treatment,
          you or your representative (with your acknowledgement and consent) may appeal that
          decision to an External Appeal Agent, an independent entity certified by the State to
          conduct such appeals.
    2.    Your right to appeal a determination that a service is not Medically Necessary
         If the Healthplan has denied coverage on the basis that the service is not Medically
         Necessary, you may appeal to an External Appeal Agent if you satisfy the following
         criteria:
         a) The service, procedure or treatment must otherwise be a Covered Service under
            this Agreement; and
         b) You must have received a final adverse determination through the first level of the
            Plan’s internal appeal process and the Healthplan must have upheld the denial, or
            you and the Healthplan must agree in writing to waive any internal appeal.
    3.    Your rights to appeal a determination that a service is experimental or investigational
         If you have been denied coverage on the basis that the service is an experimental or
         investigational treatment, you must satisfy the following criteria:
         a) The service must otherwise be a Covered Service under this Agreement; and
         b) You must have received a final adverse determination through the first level of the
            Healthplan’s internal appeal process and the Healthplan must have upheld the
            denial or you and the Healthplan must agree in writing to waive any internal appeal.




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         In addition, your attending physician must certify that you have a life-threatening or
         disabling condition or disease. A life-threatening condition or disease is one which,
         according to the current diagnosis of your attending physician, has a high probability of
         death. A disabling condition or disease is any medically determinable physical or
         mental impairment that can be expected to result in death, or that has lasted or can be
         expected to last for a continuous period of not less than twelve (12) months, which
         renders you unable to engage in any substantial gainful activities. In the case of a
         child under the age of eighteen, a disabling condition or disease is any medically
         determinable physical or mental impairment of comparable severity.
         Your attending physician must also certify that your life-threatening or disabling
         condition or disease is one for which standard health services are ineffective or
         medically inappropriate or one for which there does not exist a more beneficial
         standard service or procedure covered by the Healthplan or one for which there exists
         a clinical trial (as defined by law).
         In addition, your attending physician must have recommended one of the following:
         A service, procedure or treatment that two (2) documents from available medical and
         scientific evidence indicate is likely to be more beneficial to you than any standard
         Covered Service (only certain documents will be considered in support of this
         recommendation - your attending physician should contact the State in order to obtain
         current information as to what documents will be considered acceptable); or a clinical
         trial for which you are eligible (only certain clinical trials can be considered).
         For the purposes of this section, your attending physician must be a licensed, board-
         certified or board eligible physician qualified to practice in the area appropriate to treat
         your life-threatening or disabling condition or disease.
    4.   The External Appeal Process
         If, through the first level of the Healthplan‘s internal appeal process, you have received
         a final adverse determination upholding a denial of coverage on the basis that the
         service is not Medically Necessary or is an experimental or investigational treatment,
         you have forty-five (45) days from receipt of such notice to file a written request for an
         external appeal. If you and the Healthplan have agreed in writing to waive any internal
         appeal, you have forty-five (45) days from receipt of such waiver to file a written
         request for an external appeal. The Healthplan will provide an external appeal
         application with the final adverse determination issued through the first level of the
         Healthplan‘s internal appeal process or its written waiver of an internal appeal.
         You will lose your right to an external appeal if you do not file an application for
         an external appeal within forty-five (45) days from your receipt of the final
         adverse determination from the first level plan appeal.
         You may also request an external appeal application from New York State toll-free at
         (800) 400-8882, or its website (www.ins.state.ny.us); the New York State Department
         of Health at its website (www.health.state.ny.us) or our Member Services department
         at the toll-free number on your CIGNA Healthcare ID card. Submit the completed
         application to State Department of Insurance at the address indicated on the
         application. If you satisfy the criteria for an external appeal, the State will forward the
         request to a certified External Appeal Agent.




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         You will have an opportunity to submit additional documentation with your request. If
         the External Appeal Agent determines that the information you submit represents a
         material change from the information on which the Healthplan based its denial, the
         External Appeal Agent will share this information with the Healthplan in order for it to
         exercise its right to reconsider its decision. If the Healthplan chooses to exercise this
         right, the Healthplan will have three (3) business days to amend or confirm its decision.
         Please note that in the case of an expedited appeal (described below); the Healthplan
         does not have a right to reconsider its decision.
         In general, the External Appeal Agent must make a decision within thirty (30) days of
         receipt of your completed application. The External Appeal Agent may request
         additional information from you, your physician or the Healthplan. If the External
         Appeal Agent requests additional information, it will have five (5) additional business
         days to make its decision. The External Appeal Agent must notify you in writing of its
         decision within two (2) business days.
         If your attending physician certifies that a delay in providing the service that has been
         denied poses an imminent or serious threat to your health, you may request an
         expedited external appeal. In that case, the External Appeal Agent must make a
         decision within three (3) days of receipt of your completed application. Immediately
         after reaching a decision, the External Appeal Agent must try to notify you and the
         Healthplan by telephone or facsimile of that decision. The External Appeal Agent must
         also notify you in writing of its decision.
         If the External Appeal Agent overturns the Healthplan’s decision that a service is not
         Medically Necessary or approves coverage of an experimental or investigational
         treatment, the Healthplan will provide coverage subject to the other terms and
         conditions of this Healthplan. Please note that if the External Appeal Agent approves
         coverage of an experimental or investigational treatment that is part of a clinical trial,
         the Healthplan will only cover the costs of services required to provide treatment to you
         according to the design of the trial. The Healthplan shall not be responsible for the
         costs of investigational drugs or devices, the costs of non-health care services, the
         costs of managing research, or costs which would not be covered under this
         Agreement for non-experimental or non-investigational treatments provided in such
         clinical trial.
         The External Appeal Agent’s decision is binding on both you and the Healthplan. The
         External Appeal Agent’s decision is admissible in any court proceeding.
         The Healthplan will charge you a fee of $50 for an external appeal. The external
         appeal application will instruct you on the manner in which you must submit the fee.
         The Healthplan will also waive the fee if the Healthplan determines that paying the fee
         would pose a hardship to you. If the External Appeal Agent overturns the denial of
         coverage, the fee shall be refunded to you.
    5.    Your Responsibilities




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         It is your responsibility to initiate the external appeal process. You may initiate the
         external appeal process by filing a completed application with the New York State
         Department of Insurance. If utilization review was initiated after health care services
         have been provided, your physician may file an external appeal by completing and
         submitting the “New York State External Appeal Application For Health Care Providers
         To Request An External Appeal of a Retrospective Final Adverse Determination,”
         which will require your signed acknowledgement of the provider’s request and consent
         to release of medical records.
         Under New York State law, your completed request for appeal must be filed within
         forty-five (45) days of either the date upon which you receive written notification from
         the Healthplan that it has upheld a first level denial of coverage or the date upon which
         you receive a written waiver of any internal appeal. The Healthplan has no authority to
         grant an extension of this deadline.
         Complaints/Appeals to the State of New York
         At any time in the Grievance/Appeals process you may contact the Department of
         Health (for medically related issues) or the Department of Insurance (for
         billing/contract related issues) at the following address and telephone number to
         register your complaint.
                                  New York Department of Health
                                 Metropolitan Regional Area Office
                                      5 Penn Plaza, 2nd Floor
                                       New York, NY 10001
                                          (212) 268-6306
                                         or (800) 206-8125
                                                 or
                                     New Rochelle Area Office
                                   145 Huguenot Street, 6th Floor
                                     New Rochelle, NY 10810
                                 (914) 654-7199 or (800) 206-8125

                               New York State Insurance Department
                                     One Commerce Plaza,
                                        Albany, NY 12257
                                           (800) 342-3736




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    Notice of Benefit Determination on Grievance or Appeal
    Every notice of a determination on grievance or appeal will be provided in writing or
    electronically and, if an adverse determination, will include: (1) the specific reason or
    reasons for the adverse determination, including clinical rationale; (2) reference to the
    specific plan provisions on which the determination is based; (3) a statement that the
    claimant is entitled to receive, upon request and free of charge, reasonable access to and
    copies of all documents, records, and other Relevant Information as defined; (4) a
    statement describing: (a) the procedures to initiate the next level of appeal; (b) any
    voluntary appeal procedures offered by the plan; and (c) the claimant's right to bring an
    action under ERISA section 502(a); (5) upon request and free of charge, a copy of any
    internal rule, guideline, protocol or other similar criterion that was relied upon in making the
    adverse determination regarding your appeal, and an explanation of the scientific or clinical
    judgment for a determination that is based on a Medical Necessity, experimental treatment
    or other similar exclusion or limit.
    In addition, every notice of a utilization review final adverse determination must include: (1)
    a clear statement describing the basis and clinical rationale for the denial as applicable to
    the insured; (2) a clear statement that the notice constitutes the final adverse
    determination; (3) the Healthplan’s contact person and his or her telephone number; (4) the
    Member’s coverage type; (5) the name and full address of the Healthplan's utilization
    review agent, if any; (6) the utilization review agent's contact person and his or her
    telephone number; (7) a description of the health care service that was denied, including,
    as applicable and available, the dates of service, the name of the facility and/or physician
    proposed to provide the treatment and the developer/manufacturer of the health care
    service; (8) a statement that the Member may be eligible for an external appeal and the
    timeframes for requesting an appeal; and (9) a clear statement written in bolded text that
    the forty-five (45) day time frame for requesting an external appeal begins upon receipt of
    the final adverse determination of the first level appeal, regardless of whether or not a
    second level appeal is requested, and that by choosing to request a second level internal
    appeal, the time may expire for the Member to request an external appeal.
    You also have the right to bring a civil action under Section 502(a) of ERISA if you are not
    satisfied with the Level Two decision (or with the Level One decision for all expedited
    grievances or appeals and all Medical Necessity appeals). You or your plan may have
    other voluntary alternative dispute resolution options such as Mediation. One way to find
    out what may be available is to contact your local U.S. Department of Labor office and your
    State insurance regulatory agency. You may also contact the Plan Administrator.
    Relevant Information
    Relevant Information is any document, record, or other information which was (a) relied
    upon in making the benefit determination; (b) was submitted, considered, or generated in
    the course of making the benefit determination, without regard to whether such document,
    record, or other information was relied upon in making the benefit determination; (c)
    demonstrates compliance with the administrative processes and safeguards required by
    federal law in making the benefit determination; or (d) constitutes a statement of policy or
    guidance with respect to the plan concerning the denied treatment option or benefit for the
    claimant's diagnosis, without regard to whether such advice or statement was relied upon in
    making the benefit determination.




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    Service Standards and Requirements
    Qualified providers of OB/GYN subject to New York Public Health Law 220 are required to
    provide HIV pretest counseling with clinical recommendation of testing for all pregnant
    women. Those women and their newborns must have access to services for positive
    management of HIV disease, psychological support and case management t for medical,
    social and addictive services.
    Medical Record Reviews – Medical Record Documentation
    Additional medical record guidelines:
        •   Separate medical record for each enrollee;

        •   Record verifies that PCP coordinates and manages care

    Medical record retention requirements:
        •   Six (6) years after date of services to enrollees or cessation of HMO operation. For
            minors, six (6) years from date of majority.

    Peer Review
    Inappropriate conduct reviewed includes fraud. In addition, actions will be taken as
    appropriate in a case of imminent harm to patient health.
    Credentialing
    More information on minimum qualification standards is available upon request from
    Provider Services at 1.800.88CIGNA (882-4462).
    Recredentialing Process
    We will provide you with information, profiling data and analysis used to evaluate
    performance during any evaluation process, and upon request. We are available to discuss
    the unique nature of your professional patient population which may have bearing on your
    profile, and to work cooperatively with you to improve performance.
    Provider Termination Appeals
    If CIGNA proposes to terminate a contract, we will provide a written explanation of the
    reasons for the proposed contract termination and an opportunity for a review or hearing as
    described below. The termination notice will explain the reasons for the proposed action,
    include a notice that the provider has the right to requests a hearing on review at the
    provider’s discretion before a panel appointed by the CIGNA, and include the time limit for
    a hearing date within thirty days after the date of receipt of a request for a hearing. The
    hearing panel will be comprised of three persons appointed by CIGNA. At least one person
    on the panel in the same discipline or same specialty as the person under review. The
    panel can consist of more than three members, provided the number of clinical peers
    constitutes one-third or more of the total membership. The hearing panel shall render a
    decision a decision in a timely manner. Decisions will include one of the following and will
    be provided in writing to the healthcare: reinstatement; provisional reinstatement with
    conditions set forth by the MCO, or termination. Decisions of termination shall be effective
    not less than 30 days after receipt by the healthcare professional of the hearing panel’s



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    decision. In no event shall determination be effective earlier than 60 days from receipt of
    the notice of termination. A provider terminated due to the following is not eligible for a
    hearing or review: a case involving imminent harm to patient care, a determination of fraud,
    or a final disciplinary action by a state licensing board or other governmental agency that
    impairs the health of the healthcare professional’s ability to practice.
    CIGNA does not propose contract terminations solely for the following actions by a
    provider:
    •   advocated on behalf of an enrollee,
    •   filed a complaint against a managed care organization,
    •   appealed a decision of the managed care organization,
    •   provided information or filed a report to PHL4406-c regarding prohibitions of plans, or
        requested a hearing for review.


    Transitional Care Following Contract Termination
    If a member has been receiving care from a provider whose participation in the CIGNA
    network ends and a continued course of covered treatment is Medically Necessary, he/she
    may be eligible to receive “transitional care” from the non-participating provider for up to
    ninety (90) days. Members may also be eligible to receive transitional care if in the second
    trimester of pregnancy. In this case, transitional care may continue through delivery and
    post-partum care. Such transitional care must be approved in advance by CIGNA and the
    provider, and the must agree to accept our reimbursement rate and to abide by CIGNA's
    policies and procedures and quality assurance requirements. There may be circumstances
    where continued care by a provider no longer participating in CIGNA's network will not be
    available, such as when the provider loses his or her license to practice or retires.”



Connecticut
    Subrogation/Worker’s Compensation

    Subrogation applies if the member is injured in an accident of any type and someone else is
    responsible for the injury. Examples may include motor vehicle accidents, dog bites, slips
    and falls, or the results of an act by a third party. State law may prohibit recovery of
    subrogation claims in certain circumstances.

    Utilization Review

    If a mother and newborn are discharged earlier than the 48 or 96 hours, plans must provide
    coverage for 2 follow-up visits, as described in the member’s Plan Documents.

    Precertification Protocol

    Precertification of coverage is not requires for emergency services. However, emergency
    services resulting in a hospital admission should be reported on the day of admission to a
    member’s primary care physician where applicable and to CIGNA HealthCare if CIGNA has
    weekend and after-hours coverage or within 24 hours or the next business day for
    remaining locations.




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    Referrals

    Child Early Intervention services do not require a referral for a specialist to provide services
    to assess or provided as part of an individualized family services plan (IFSP)

Pennsylvania
    (1) With respect to Emergency Services:

       (a) Emergency Services: Any health care service provided to a member after the
           sudden onset of a medical condition that manifests itself by acute symptoms of
           sufficient severity or severe pain, such that a prudent layperson, who possesses an
           average knowledge of health and medicine, could reasonably expect the absence of
           immediate medical attention to result in one or more of the following:

            (a) Placing the health of the member, or, with respect to a pregnant woman, the
            health of the woman or her unborn child, in serious jeopardy;

            (b) Serious impairment to bodily functions;

            (c) Serious dysfunction of any bodily organ or part.

            Coverage for emergency services provided during the period of the emergency shall
            include evaluation, testing, and if necessary, stabilization of the condition,
            emergency transportation and related emergency care provided by a licensed
            ambulance service.

       (b) If the member is admitted to a hospital or other health care facility, the emergency
           health care provider shall notify CIGNA HealthCare of the emergency services
           delivered within 48 hours or on the next business day, whichever is later. An
           exception to this requirement will be made where the medical condition of the
           member precludes the provider from accurately determining the member’s benefit
           plan.

    (2) With respect to Quality Management:

        CIGNA HealthCare shall evaluate its Quality Management Program annually and
        include a report to the board of directors, or the quality assurance or quality
        improvement committee, which addresses the appropriateness of clinical criteria; the
        consistency of decision making through the conduct of reliability studies of staff
        application of utilization criteria; staff resources and training; and the timeliness of
        decisions.

    (3) With respect to the Credentialing Process:

         (a)    At a minimum, for PCPs and specialists, the following credentialing
                elements shall be verified:

                (1) Current licensure.

                (2) Education and training.




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                (3) Board certification status.

                (4) Drug enforcement administration certification status.

                (5) Current and adequate malpractice coverage.

                (6) Malpractice claims history.

                (7) Work history.

                (8) Hospital privileges if the provider provides services at hospitals.

                (9) Any other information the Department of Health may require.

            (b) At a minimum, for non-PCPs and nonspecialists, current licensure and
                malpractice coverage shall be verified, to the extent licensure and coverage is
                required by State or Federal law.

    Dispute Resolution for Pennsylvania

    I.    Overview of Dispute Resolution Process.

          CIGNA has three (3) types of internal dispute resolution processes to resolve the
          various disputes which may arise between CIGNA and Provider. These processes will
          be described in greater detail below.

          A. Termination Dispute Resolution Process. Disputes pertaining to the termination
             of the Agreement (including termination resulting from Provider’s failure to provide
             CIGNA with requested recredentialing information on a timely basis and CIGNA’s
             termination of the Agreement for business reasons) will be resolved through this
             process.

          B. Act 68 Dispute Resolution Process. With respect to medical necessity denials
             for health care services provided to Participants covered by a Benefit Plan which is
             subject to the Pennsylvania Quality Health Care Accountability and Protection Act
             (“Act 68”), if Provider obtains the member’s consent to appeal such a denial,
             Provider may appeal through this process.

          C. Informal Dispute Resolution Process. If Provider does not have the Participant’s
             consent to appeal a payment denial, or if the Participant is covered by a Benefit
             Plan which is not subject to Act 68 (for example, the Participant is covered by a
             self-funded plan) Provider may appeal a denial of payment for a health care
             service (on the grounds of medical necessity or for administrative reasons) in
             accordance with this process.

    II.   Details of Dispute Resolution Processes

          A. Termination Disputes Resolution Process. For all disputes pertaining to the
             termination of the Agreement (including termination resulting from Provider’s failure
             to provide CIGNA with requested recredentialing information on a timely basis and




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                CIGNA’s termination of the Agreement for business reasons), CIGNA has a two
                level internal appeal process and an arbitration of disputes process:

                1.     Internal Review of Disputes

                       a.   First Level Review. In the event that Provider has a dispute with respect
                            to termination of the Agreement, the dispute shall be submitted for review
                            and resolution to the CIGNA designee identified by CIGNA in CIGNA’s
                            termination letter, as applicable (the “First Level Review”). Provider must
                            submit a request for a First Level Review of a termination dispute within
                            30 days of the date of the termination letter. The appeal will be scheduled
                            within 30 days of receipt of request for the appeal. The appeal of the
                            termination will be decided by a panel of at least three Providers who were
                            not involved in the original decision. Provider may bring third parties with
                            them to the appeal and may present information to the panel. The decision
                            shall be communicated to Provider within 5 days. There is no cost to
                            Provider for requesting a First Level Review.

                       b.   Second Level Review. If Provider is not satisfied with the resolution at
                            the First Level Review, Provider may submit the matter for a second level
                            review to the CIGNA designee identified in the First Level Review decision
                            letter (the “Second Level Review”). Provider must submit a request for a
                            Second Level Review within 60 days of the date of the letter
                            communicating the First Level Review decision. The Second Level Review
                            is sent to the National Medical Director or his designee and is reviewed by
                            a committee of nurses and Providers employed by CIGNA HealthCare, at
                            the next available meeting of such committee. The decision of the
                            committee shall be communicated to Provider within five days of the
                            decision. There is no cost to Provider for requesting a Second Level
                            Review. The Second Level Review decision will be binding on CIGNA and
                            Provider if the resolution is accepted by Provider.

           2.        Arbitration of Disputes

                     In the event that Provider’s termination dispute as described above is not
                     resolved through the aforementioned process, Provider may initiate arbitration by
                     providing written notice to CIGNA. Written acknowledgment of Provider’s request
                     for arbitration shall be made within15 days after the receipt of the request for
                     arbitration. The arbitration process is set forth in the Dispute Resolution section
                     of this Physician and Health Care Practitioner Reference Guide

           3.        If Provider fails to request a First Level Review, Second Level Review or
                     Arbitration of Provider’s termination dispute within the applicable timeframes,
                     CIGNA’s last determination regarding the dispute shall be binding on Provider.

        B. Act 68 Dispute Resolution Process

            With respect to medical necessity denials for health care services provided to
            Participants covered by a Benefit Plan which is subject to the Pennsylvania Quality



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            Health Care Accountability and Protection Act (“Act 68”), if Provider obtains the
            member’s consent to file a written grievance regarding such a denial, Provider may
            appeal through this process, which shall comply with Act 68 and regulations
            promulgated there under. An acceptable form of consent is found at the end of this
            Dispute Resolution policy. Examples of disputes which may be resolved through this
            process (with the Participant’s consent) include:

            (i)     Disapproval of full or partial payment for a requested health care service;

             (ii) Approval of the provision of a requested health care service for a lesser scope
                  or duration than requested;

            (iii)   Disapproval of payment of the provision of a requested service but approval of
                    payment for the provision of an alternative health care service;

            (iv)    Denial of an emergency claim on the basis that the condition did not meet the
                    definition of an emergency;

            (v)     Denial of a request by a Participant for a referral to a non-participating Provider
                    with special skills, knowledge, experience or reputation regarding the
                    performance of a needed procedure or treatment, on the basis that the
                    procedure or treatment can be rendered appropriately by a participating
                    Provider;

            (vi)    Denial of a request for an organ transplant on the basis that the existence of
                    complicating medical factors and the patient’s condition make a transplant
                    inappropriate;

            (vii) Denial of a prescription drug on the basis that the drug is not part of the
                  managed care plan’s approved formulary;

            (viii) Denial of a request for treatment at or by a non-participating Provider on the
                   basis that a participating Provider is available to provide such treatment or
                   service;

            (ix)    Discharge from a facility on the basis that the continued stay is no longer
                    medically necessary;

            (x)     Refusal to continue to pay for skilled nursing facility care on the basis that
                    continued care is not medically necessary at the skilled nursing care level, but
                    rather is custodial in nature;

            (xi)    Denial of a referral to a specialist.

            Once Provider assumes responsibility for filing a grievance, Provider may not bill
            Participant for services provided that are the subject of the grievance until the
            external grievance review has been completed or the Participant rescinds consent
            for Provider to pursue the grievance. Provider, having obtained consent from
            Participant to file a grievance, shall have 10 days from receipt of a denial described
            above and any decision from a first, second or external review upholding CIGNA’s




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            decision, to notify the Participant or the Participant’s legal representative of its
            intention not to pursue a grievance.

            The Act 68 Process includes two (2) internal levels of review and one external level
            of review.

            1.   First Level Act 68 Review.

                 If Provider wishes to submit a grievance through the Act 68 Dispute Resolution
                 Process and has the Participant’s consent to submit a grievance, the dispute
                 shall be submitted for review and resolution to the CIGNA designee identified in
                 CIGNA’s explanation of payment (the “First Level Act 68 Review”). The First
                 Level Act 68 Review shall be reviewed by a person who did not previously
                 participate in the decision to deny payment for the health care service, who is a
                 licensed Provider, or where appropriate, an approved licensed psychologist, in
                 the same or similar specialty that typically manages or consults on the health
                 care service. The First Level Act 68 Review shall be completed within 30 days
                 of receipt of the request.

                 A written notification regarding the decision shall be provided to Provider and
                 Participant within five (5) business days of the decision. The decision shall
                 include the basis and clinical rationale for the decision and the procedure to file
                 a request for a second level review of the decision. There is no cost to Provider
                 for requesting a First Level Act 68 Review.

            2.   Second Level Act 68 Review.

                 If Provider is not satisfied with the resolution of the First Level Act 68 Review,
                 Provider may request a second level review, which shall be reviewed by a
                 committee consisting of Three persons who did not previously participate in the
                 decision to deny payment for the health care service (the “Second Level Act 68
                 Review”). One of the committee members shall include a licensed Provider, or,
                 where appropriate, an approved licensed psychologist, in the same or similar
                 specialty that typically manages or consults on the health care service. The
                 Provider and Participant shall be given written notification of their right to
                 appear in person before the committee. If the Participant or Provider cannot
                 appear at the hearing in person, they shall be given the opportunity to
                 communicate with the committee by telephone. The Second Level Act 68
                 Review shall be completed within 45 days of receipt of a request for such
                 review. The written decision of the committee shall be provided to Provider and
                 Participant within 5 business days of the decision and shall include the basis
                 and clinical rationale for the decision and the procedure for filing an external
                 grievance. There is no cost to Provider for requesting a Second Level Act 68
                 Review.

            3.   External Review.

                 If Provider is not satisfied with the resolution at the Second Level Act 68
                 Review, Provider may request an external review of the decision following



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                receipt of a Second Level Act 68 Review decision. The filing for external review
                must include all material justification and all reasonably necessary supporting
                information that has not previously been provided to CIGNA. Provider must
                request an external review within 15 days of receipt of the decision from the
                Second Level Act 68 Review. Provider shall provide the name of the Participant
                involved and a copy of the Participant’s written consent for Provider to file a
                grievance.

                If Provider requests external review under this Act 68 Dispute Resolution
                Process, all fees and costs related to the external review shall be paid by the
                nonprevailing party. Provider and CIGNA shall each place in escrow an amount
                equal to one-half of the estimated costs of the external review process.

                The external review shall be conducted by a Certified Utilization Review Entity
                “CRE” not directly affiliated with CIGNA. Within five business days of receiving
                the external grievance from Provider, CIGNA shall notify the Pennsylvania
                Department of Health (the “Department”), the Participant and Provider that a
                request for an external review has been filed. Within 15 business days of
                receipt of the request for an external grievance review, CIGNA shall provide
                Participant and Provider with the list of documents being forwarded to the CRE.
                Provider, within 15 business days of receipt of notice that the request for an
                external grievance review was filed with CIGNA, may submit additional
                information to the CRE for consideration and shall provide copies of such
                additional information to CIGNA.

                Either party has 7 business days from the date on the notice of assignment of
                the CRE to object orally or in writing to the Department about the assigned CRE
                based on conflict of interest. Within 60 days of the receipt of the request for
                external review, the CRE conducting the external review shall issue a written
                decision to CIGNA, the Participant, Provider and the Department, including the
                credentials of the reviewer, the basis and clinical rationale for the decision. The
                decision of the external reviewer shall be subject to appeal to a court of
                competent jurisdiction within 60 days of receipt of notice of the external review
                decision. There shall be a rebuttable presumption in favor of the decision of the
                CRE conducting the external review.

      C. Informal Dispute Resolution (“IDR”) Process.

           If Provider does not have the Participant’s consent to appeal a payment denial, or if
           the Participant is covered by a Benefit Plan which is not subject to Act 68 (for
           example, Participant is covered by a Benefit Plan between CIGNA or CIGNA Affiliate
           and a self-funded Payor), Provider may appeal a denial of payment for a health care
           service in accordance with this process. Examples of disputes which may be
           resolved through this process include:

           •   Denied inpatient stays/length of stay or level of care challenges where Provider
               has NOT indicated that Provider is appealing on behalf of the Participant.




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           •    ClaimCheck challenges.

           •    Fee/discount discrepancies.

           •    Untimely claim filing denials.

           •    Denials based upon Provider’s failure to contact CIGNA to secure any required
                prior authorization.

           •    Denials based on violation of the Delayed Treatment Days provision.

           The IDR Process includes two internal levels of review and an arbitration of disputes
           process.

           1.   First Level IDR Review

                If Provider wishes to appeal pursuant to the IDR process, provider submits the
                appeal of the payment dispute to the CIGNA designee identified by CIGNA in
                CIGNA’s explanation of payment (the “First Level IDR Review”). Provider must
                submit a request for a First Level IDR Review within 180 days of the date of the
                initial explanation of payment, or if the appeal relates to a claim that was
                adjusted by CIGNA, within 180 days from the date of the last payment
                adjustment. The First Level IDR Review shall be completed within 30 days after
                receipt of the request for such review. The decision shall be communicated to
                Provider within 15 days of completion of the First Level IDR Review.
                Administrative appeals (i.e. untimely claim filing, claim check challenges) are
                reviewed by an appeal processor or a nurse. Medical necessity appeals are
                initially reviewed by a nurse. If the nurse cannot overturn the appeal, it is
                reviewed and decided by a Provider. There is no cost to Provider for requesting
                a First Level IDR Review.

           2. Second Level IDR Review

                If Provider is not satisfied with the resolution at the First Level IDR Review,
                Provider may submit the matter for a second level review to the CIGNA designee
                identified in the First Level Review decision letter (the “Second Level IDR
                Review”). Provider must submit a request for a Second Level IDR Review within
                60 days of the date of the letter communicating the First Level IDR Review
                decision. The Second Level IDR Review shall be considered within 30 days after
                the receipt of the request for such review. Administrative appeals (i.e., untimely
                claim filing, claim check challenges) are reviewed by an appeal processor or a
                nurse. Medical necessity appeals are initially reviewed by a nurse. If the nurse
                cannot overturn the appeal, it is reviewed and decided by a Provider. The
                decision shall be communicated to Provider within 15 days of completion of the
                Second Level IDR Review. The Second Level IDR Review decision will be
                binding on CIGNA and Provider if the resolution is accepted by Provider. There
                is no cost to Provider for requesting a Second Level IDR Review.




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           3.   External Review/Arbitration of Disputes.

                In the event that Provider is not satisfied with the Second Level IDR Review
                decision payment dispute Provider may initiate arbitration by providing written
                notice to CIGNA. With respect to a Provider payment dispute, Provider must
                submit a request for arbitration within one year of the date of the letter
                communicating the Second Level IDR Review decision. The arbitration process
                is set forth in the Dispute Resolution section of this Physician and Health Care
                Practitioner Reference Guide. Written acknowledgment of Provider’s request for
                arbitration shall be made within 15 days after the receipt of the request for
                arbitration.

           4.   If Provider fails to request a First Level IDR Review, Second Level IDR Review
                or Arbitration of Provider’s payment dispute within the applicable timeframes,
                CIGNA’s last determination regarding the dispute shall be binding on Provider.
                Provider shall not bill the Participant for payments that are denied on the basis
                that Provider failed to submit the request for review or arbitration within the
                required timeframes.




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Patient Consent Form
Notice is hereby given that, pursuant to 28 Pa. Code §9.603, the Department of Health, Bureau
of Managed Care (the Department), is issuing a technical advisory on enrollee consent for
provider-initiated grievances.
The Department is aware plans and providers have been disagreeing regarding what
constitutes a valid enrollee consent allowing a provider to go forward with a grievance. Similar
issues surfaced during the Department’s promulgation of its regulations relating to managed
care organizations (28 Pa. Code ch. 9). Because of these disputes, the Department included, in
§9.706(e), the minimum elements that a consent form should have in order to be compliant with
the regulations. (28 Pa. Code §9.706(e)). Despite this regulation, plans and providers continue
to dispute the size, shape, color and language included in these forms, and these arguments
over form are jeopardizing the enrollee’s right to have a provider bring a grievance with the
enrollee’s consent. The Department, therefore, is issuing a sample consent forms, which, if a
provider and enrollee follow its format, will be deemed by the Department to be compliant with
28 Pa. Code §9.706, and constitute valid enrollee consent for the purpose of a provider
grievance.
The Department is also issuing an advisory regarding the proper interpretation of §9.7-6(b) and
§9.706(e)(5). Some plans have viewed these two sections as contradictory in a hospital setting,
since the first allows a provider to obtain enrollee consent at the time of treatment, and the
second states that the consent form must include the specific service for which coverage was
provided or denied. With respect to the policy behind §9.706(b), the Department stated in the
Preamble to Final Rulemaking:
       The Department is willing to permit a health care provider to use an enrollee consent
       obtained prior to services, so long as that consent is not obtained as a condition
       precedent to the enrollee’s receiving the service. The Department is aware that some
       providers serve populations who may be difficult to locate after the service has been
       rendered. The Department is also aware that some enrollee, not being held financially
       responsible for the service in any case, may have no motivation to support the provider’s
       pursuit of a grievance. If the provider does not obtain consent at the time of the service,
       the provider may have difficulties in obtaining consents at a later date.
31 Pa. B. 3114 (June 9, 2001). This remains the Department’s position. Therefore, in a hospital
admission setting, the Department will deem compliant with both subsections (b) and (e)(5) a
statement in the enrollee consent form that the specific services for which the enrollee is
providing consent are related to the hospital admission, and the dates of that admission. The
consent would then be valid for all services provided during that admission.




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Patient Consent for My Provider to File a Grievance on my Behalf with
my Health Insurance Plan

Provider Name:                                                    Provider Plan ID Number:


Provider Address:


Description of services that may be appealed:                     Date(s) services were provided:


I agree to allow this health care provider to file a grievance on my behalf with the following
health plan if there is a question about coverage for the services listed below.
I understand that:
    1. If I consent, I will not be able to file my own grievance concerning these same services,
        nor will any representative I appoint, unless this consent is rescinded in writing.
    2. I have a right to rescind this consent at any time. My legal representative has the right to
        rescind this consent at any time.
    3. This consent shall be automatically rescinded if my health car provider does not file a
        grievance, or stops grieving my case.
I have read this consent or have had it read to me, and it has been explained to my satisfaction.
I understand the information in the consent form, and grant my consent to this provider to file a
grievance on my behalf.

Print Provider Name:                                Patient Date of Birth:    Health Insurance Company:


Patient Address:                                                              Patient Insurance ID Number:


Patient Signature:                                                            Signature Date:




The above named enrollee is unable to sign this consent form because of the following reasons and I consent for
the above named enrollee:


Print Representative Name:                                                     Relationship to Patient:


Representative Signature:                                                      Signature Date:




Print Witness Name:                    Witness Signature:                     Signature Date:




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The Importance of Well Care Visits
What Is a Well Care Visit?
Routine well care visits are important aspects for the child’s growth and development. Primary
physician evaluates many aspects of the child’s needs such as:

• physical examination
• immunization updates
• tracking growth and development
• finding any problems before they become serious
• information on health and safety issues
• information on nutrition and physical fitness
• information on how to manage emergencies and illnesses
Furthermore, primary physician provide anticipatory guidelines on the following aspects such as:

• behavioral problems
• learning problems
• emotional problems
• family problems
• socialization problems
• puberty and concerns about teenage years

Acceptable Codes For Well Care Visits
Some of the most widely use codes for well care visit are the following:

CPT Codes:          99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99432.

ICD-9-CM Codes: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

If you would more like more information on recognized codes by, please contact the Quality
Management Department. 1.800.210.9122.


Local Specialty Networks
Home Health Services
CareCentrix
CareCentrix provides or arranges for the delivery of covered home health and home infusion
services. To order services or equipment, contact CareCentrix at 1.800.411.2305. CareCentrix
will arrange for these services to be delivered to your patients.
The information needed to complete an order includes:




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• Patient information including last name, first name, middle initial and phone number
• Patient ID Number
• Address where service is to be rendered, including the telephone number and zip code
• Patient date of birth (age), sex and Social Security Number
• Facility name and telephone number
• Allergies
• Ordering physician (who will follow patient in the community) and office telephone number
• Start-of-care date requested
• All pertinent diagnoses and/or surgical procedures with onset and/or exacerbation dates
• Specific orders/treatment (including frequency, type of dressing, drug, dosage, etc.).
Apria
Apria is our network provider for durable medical equipment (e.g. beds, wheelchairs, walkers),
respiratory equipment (e.g., O2, CPAP, ventilators), and enteral nutrition (e.g., pumps and
nutritional support). Contact Apria at 1.800.901.3566 or via fax at 1.800.723.4288.

Chiropractic Services
American Specialty Health Networks (ASHN)
Service Area: Connecticut, New Jersey, New York, Delaware and Southeastern Pennsylvania.

**Please note this does not include the Syracuse NY network.

ASHN is responsible for all HMO/Managed Care chiropractic network management, utilization
management and claims management services for CIGNA HealthCare members in these
states.

To refer a patient to ASHN, you need to provide a prescription order with the directions to
“evaluate and treat.” CIGNA HealthCare Open Access members may self-refer to a participating
ASHN provider for the initial 5 visits.

ASHN will manage treatment after the initial evaluation is completed.

American Specialty Health Network
P.O. Box 509001
San Diego, CA 92150-9001

For general inquiries you may call ASHN Provider Services Department at 1.800.972.4226

Physical and Occupational Therapy
OrthoNet
Service Area: New York, New Jersey and Connecticut

**As of 02/01/06, OrthoNet handles physical and occupational therapy for Delaware and
Eastern Pennsylvania.



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Please note this does not include the Syracuse NY network.

OrthoNet is responsible for all physical and occupational therapy network management,
utilization management and claims management services for CIGNA HealthCare members in
these areas.

To refer a patient to OrthoNet, you need only provide a prescription order with the directions to
“evaluate and treat.” OrthoNet will manage treatment after the initial evaluation is completed.

Address
OrthoNet LLC,
1311 Mamaroneck Avenue, Suite 240,
White Plains, NY 10605

For general inquiries you may call OrthoNet’s Provider Services Department at 1.866.874.0727,
Option 2

Rehabilitation Provider Network (RPN)
Service Area: Delaware and Central/South East Pennsylvania

Please note: RPN applies to these networks until 01/31/06. As of 02/01/06, OrthoNet takes over
the physical and occupational therapy networks. Speech therapy will be handled by CIGNA
HealthCare directly.
RPN has contracted with CIGNA HealthCare to provide outpatient physical therapy,
occupational therapy, and speech therapy in Pennsylvania and Delaware. RPN is the exclusive
provider for HMO members and the preferred provider for PPO members. Members or providers
who are looking to identify an RPN site should call 1-888-758-9553 for locations close to them.

Laboratory Services
Quest Diagnostics
Service Area: Connecticut, New Jersey, New York, Delaware and Central/South East
Pennsylvania

Quest Diagnostics has contracted with CIGNA HealthCare to provide all outpatient diagnostic
laboratory and pathology services for CIGNA HealthCare members.

Quest Diagnostics provides:

• STAT testing locations
• Freestanding laboratory sites (Patient Service Centers)
• Hospital labs (not all hospital labs in the CIGNA HealthCare network participate for
  laboratory services)




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To establish an account with Quest Diagnostics, please call 1.877.567.0739. Once an account
has been established, a Quest Diagnostics representative will call your office to schedule and
conduct an orientation. The representative will review Quest Diagnostics requisitions, supplies,
Patient Service Center Locations, STAT services and pickup arrangements. When referring
patients to a Quest Diagnostics Patient Service Center, please provide the patient with a
completed Quest Diagnostics Test Requisition Form.

Please call or provide the patient with the Patient Service Center locator number for the nearest
Quest Diagnostics site. The locator number is 1.800.377.7220.For the address of the Quest
Diagnostics Claim center nearest to you, please call 1.800.982.6810, opt 1.

Radiology Services
American Imaging Management (AIM)
Service Area: Connecticut, New York and New Jersey

Please note this does not include the Syracuse NY network.

American Imaging Management (AIM) is the diagnostic radiology vendor for all outpatient
diagnostic radiology services for CIGNA HealthCare HMO and OAP members in the service
area listed above. All outpatient radiology services for HMO and OAP members must be
provided by an AIM participating provider.

The ordering practitioner refers an HMO/OAP member to a participating AIM facility by providing
the member with a prescription that includes the name of the exam requested. The member
takes the prescription to a participating AIM facility.

To locate a participating AIM facility, the ordering practitioner may call AIM’s Customer Service
Department at 1.800.252.2021 or visit the AIM website at www.americanimaging.net.

Prior authorization is required for the following studies:

• CT Scans
• MRI
• MRA
• Nuclear Cardiology
• PET Scans
It is the responsibility of the ordering practitioner to call AIM for prior authorization, and the
responsibility of the imaging provider to verify prior authorization has been obtained.

There are three separate ways to request prior authorization from AIM:

1.   Call – 1.800.252.2021.

2.   Internet – Log on to AIM’s secure website at www.americanimaging.net to request prior
     authorization in real time 24 hours a day, 7 days a week.




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3.   Fax – Complete the AIM Precertification/RQI Request Fax Form and fax your request to
     800.610.0050. A copy of the AIM Preauthorization/RQI Request Fax Form is located on the
     following page or you may download a copy of this form from the AIM web site at
     www.americanimaging.net.
AIM’s Prior Authorization Department is open from 8 a.m. to 5 p.m., Monday through Friday. To
request prior authorization for a procedure, please call 1.800.859.5288 and provide the following
information:

• Member’s name, CIGNA HealthCare ID number and date of birth
• Ordering practitioner’s name and address
• Name of imaging facility where the procedure will be performed
• Name and CPT code of the imaging procedure
• Reason (indication for the imaging procedure and/or ICD-9 CM diagnostic code)
• Results of pertinent previous studies (labs, x-rays, etc.) and treatments
• Member’s symptoms
The following services are excluded from the AIM arrangement and will be reimbursed by
CIGNA HealthCare directly:

• Radiation Therapy
• Cardiac Ultrasounds
• Cardiovascular Stress Tests
• Radiology procedures done in conjunction with infertility treatments
• Nuclear Therapy
• Echocardiography
• EEGS
• EKGS
• Cardiac Catherization
AIM Web-Based Services
You may access AIM on line 24 hours a day, 7 days a week. The website applications are
designed to allow providers access to AIM claims, provider network, preauthorization and
eligibility information. To reach the AIM on-line applications and services, please visit
www.americanimaging.net and click on Applications Login to register for your secure ID and
Password.

In-Office Imaging Privileges for Non-Radiologists
AIM is responsible for assessing, contracting and reimbursing with certain specialists to perform
specific radiology services in the practitioner’s office for Northern New Jersey, New York and
Connecticut. Imaging privileges for non-radiologists may be established by contracting directly
with AIM. To apply for in-office imaging privileges, call the AIM Customer Service Department at
1.800.252.2021. A practitioner who has been approved and contracted for in-office imaging



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CIGNA HealthCare                                    Introduction & Important Information
Physician & Health Care
Practitioner Reference Guide

privileges will be reimbursed as outlined in the practitioner’s direct contract with AIM.
Practitioners who are not approved to perform in-office imaging must refer members to an AIM
participating location.

MedSolutions, Inc.
Service Area: Delaware and Central/South East Pennsylvania

CIGNA HealthCare has a national relationship with MedSolutions, Inc., the nation’s largest high-
tech radiology management company. MedSolutions offers utilization and network management
of outpatient high-tech radiology services including CT, MR and PET imaging studies for
members covered by both managed care and PPO plans.
Primary care and specialty providers must contact MedSolutions to precertify coverage for non-
emergency outpatient MR, CT, and PET imaging studies. (Contact MedSolutions at
1.888.693.3211 or at www.medsolutions.com.)
Freestanding imaging centers and hospitals should coordinate MRA, MRI, CT scans and PET
scans for CIGNA HealthCare participants directly with MedSolutions.

Radiology procedures performed during an inpatient or emergency department visit do not
require precertification from MedSolutions.
If you have any questions about MedSolutions, call 1.800.467.6424 or you can reach them at
www.medsolutions.com.

Vision Care
Vision Service Plan (VSP)
Service Area: New Jersey, New York, Connecticut, Delaware and Southeastern Pennsylvania

Vision Service Plan (VSP) is the CIGNA HealthCare contracted vision care vendor for managed
care members with a VSP vision rider for routine eye exams/materials. HMO/Managed Care
members may self-refer to a participating VSP provider for routine vision exams or primary eye
care as allowed by the member’s benefits. If a member’s benefit plan includes vision care
benefits, he or she may access a wide range of routine eye care services through VSP.

To access vision care benefits, the member may contact a VSP participating provider to make
an appointment. For help locating a VSP participating provider, call VSP at 1.800.877.7195. The
website address for VSP is www.vsp.com.




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CIGNA HealthCare                                                                               Pr
Physician & Health Care                                       Provider Participation
Practitioner Reference Guide


Provider Participation
CIGNA HealthCare contracts with individual physicians, physician groups, associations and
delivery systems, hospitals, ancillary facilities and other health care professionals to participate
in our service networks and care for our members.
As a participating provider, you must meet the CIGNA HealthCare standards of training,
licensure and performance prior to network participation. You also will be evaluated on an
ongoing basis to ensure continued qualification. Performance requirements include providing
quality services to members and cooperating with CIGNA HealthCare administrative and
medical management programs.

Primary Care Physician (PCP) Services
The primary care physician (PCP) coordinates all aspects of care for members who choose a
PCP. Coordinating a member’s care can include providing treatment, referring to specialists or
other health care professionals, and requesting precertification of coverage.
A PCP may practice in the field of family practice, general medicine, internal medicine, or
pediatrics. Other specialties may be designated as PCPs depending upon state laws. For
managed care plans, members are required or encouraged to select a PCP to manage their
health care needs.
PCPs must comply with CIGNA HealthCare medical management programs, including
Utilization Management, Quality Management, Preventive Care Guidelines and Prescription
Drugs.

Specialty Care Physician (SCP) Services
The specialty care physician (SCP) provides specialty medical services to CIGNA HealthCare
members referred by a PCP or the member in accordance with plan benefits.
An SCP coordinates the CIGNA HealthCare member’s care with the PCP to ensure compliance
with CIGNA HealthCare’s medical management requirements. This includes verifying referrals
or precertification requirements prior to treating members (if applicable), referring requests back
to the PCP for additional services or referrals to other SCPs, and communicating findings and
treatment plans to the PCP on a timely basis.
An SCP accepts referred members from network providers and renders services as appropriate.
The SCP must comply with CIGNA HealthCare medical management programs, including
Utilization Management, Quality Management, and Prescription Drug Programs.




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CIGNA HealthCare                                                         Provider Participation
Physician & Health Care
Practitioner Reference Guide


Service Standards and Requirements
CIGNA HealthCare members expect quality service from physicians, health care professionals,
hospitals and ancillary facilities. These standards are monitored through provider site visits,
medical record reviews, and member surveys. You can assist us in maintaining quality service
by adhering to the following standards and requirements.

Acceptance and Transfer of Members
You should not refuse or fail to provide services to any member unless you are incapable of
providing the necessary services or as otherwise provided in the Closing a Panel section that
follows. You are expected to provide services to members in the same manner, in accordance
with the same standards, and with the same time availability, as provided to other patients.
You may not seek or require the transfer of any member to another CIGNA HealthCare
participating provider due to the member’s utilization patterns. There may at times be a material
breakdown in the physician-patient relationship. You may request a member be removed from
your panel. Such requests are evaluated according to the CIGNA HealthCare criteria for
removal of a member. Members must be given at least 30 days advance notice of a transfer.

Closing a Panel
CIGNA HealthCare encourages primary care physicians to have a large CIGNA HealthCare
member panel whenever possible.
If you are a PCP, you may close your panel to new CIGNA HealthCare members under several
conditions. You must provide CIGNA HealthCare 30 days advance written notice and evidence
that the number of CIGNA HealthCare members in the patient panel exceeds the number of
patients in the panel who are members of any other single managed care organization; or a
statement that you are closing your practice to all new patients.
You must reopen your panel to new CIGNA HealthCare members if the acceptance of new
patients causes the number of patients who are members of any other single managed care
organization to exceed the number of CIGNA HealthCare members in your patient panel. In
addition, even when closed, you must accept CIGNA HealthCare members who were paneled
at the time of panel closure regardless of whether the patient was seen. You cannot refuse to
accept existing patients who become new CIGNA HealthCare members as a result of switching
from a plan that is insured or administered by another organization.
CIGNA HealthCare will make necessary changes to its database and directory to reflect the
physician’s closed panel status.

Member Removal from a PCP Panel
If you are a PCP, you may request a patient be removed from your panel. Such requests are
evaluated according to the CIGNA HealthCare criteria for removal of a member. Patients must
be given 30 days advance notice of a transfer.
A request to have a member choose another physician should be based on unmanageable
personality differences or related conflicts and not on patterns of utilization or diagnosis. You
have the right to request removal of a member from your panel when the member:




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CIGNA HealthCare                                                         Provider Participation
Physician & Health Care
Practitioner Reference Guide


1. Permits a non-member to use a membership card to obtain services and benefits.
2. Obtains or attempts to obtain services or benefits by means of false, misleading or
   fraudulent information, acts or omissions.
3. Repeatedly fails to pay copayments, coinsurance or deductibles required under their plan.
4. Is unable to establish a satisfactory physician-patient relationship after a strong effort by the
   provider to establish such a relationship.
5. Exhibits behavior that is disruptive, unruly, abusive or uncooperative, such that the
   provider’s ability to provide services to the member or to any other member is seriously
   impaired.
6. Threatens the life or well-being of you or your staff.

When your request to discontinue treating a member is approved by CIGNA HealthCare, you
must provide 30 days advance written notice to the member. The notice must be sent to the
member via certified mail with a copy to CIGNA HealthCare. You must continue to provide
necessary covered services to the member until the change is completed.

Communication to Members of Provider Termination
If you or CIGNA terminate your participation with respect to any of our benefit plan types,
CIGNA will notify affected members of the termination to the extent required by applicable law
and applicable accrediting requirements. Such notification will occur prior to the effective date of
the termination unless CIGNA does not receive sufficient advance notice. In this instance,
CIGNA will notify members as soon as reasonably possible. You are responsible for providing a
listing of members affected by the termination within seven business days of the date of the
notice of termination.

Office Hours and Accessibility
Members must have access to medical care within a reasonable length of time.
You must have scheduled office hours for at least 24 hours per week. PCPs and SCPs must be
available to provide services to members 24 hours per day, every day of the year. Best efforts
must be made to ensure a CIGNA HealthCare participating provider is on call and available
when the office is closed.
There must be a publicized telephone number for members to call and telephone calls must be
answered promptly. Individuals who answer calls must be trained in the appropriate response to
medical calls of a routine, urgent or emergent nature. If the phone is answered by an answering
machine, the message must give emergency instructions.




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CIGNA HealthCare                                                       Provider Participation
Physician & Health Care
Practitioner Reference Guide



Appointments and Scheduling Guidelines
You should ensure members have access to timely appointments and scheduling.
Emergent or high risk cases should have access to immediate appointments, appropriate
emergency room authorization or direction to dial 911.
Urgent cases should have access to appointments within 24 hours.
Non-urgent, symptomatic or routine appointments should be scheduled within seven to 14 days.
Preventive screenings and physicals should be scheduled within 30 days.
Generally, obstetric prenatal care for non-high risk and non urgent situations should be provided
within 14 days in the first trimester, within seven days in the second trimester and three days in
the third trimester.

Professional Services
All services must be provided by duly licensed, certified or otherwise authorized professional
personnel and at facilities that comply with:
• Generally accepted medical and surgical practices
• State and federal law
• Accreditation organization standards

Cooperation with Programs
CIGNA HealthCare is committed to promoting quality services for our members. To support this
commitment, we require your cooperation with CIGNA HealthCare programs, including
administrative programs such as claim appeals, wellness and other medical management
programs.
Cooperation with CIGNA HealthCare in establishing and implementing policies and programs to
comply with regulatory, contractual or accreditation requirements of Health Plan Employer Data
Information Set (HEDIS®),* National Committee for Quality Assurance (NCQA), and any other
applicable accreditation organization is equally important.
*HEDIS® is a registered trademark of NCQA.

Member Billing
Collect copayments at the time of service. Do not collect coinsurance and deductibles at the
time of service. For all members with coinsurance and/or deductible requirements, you are
required to submit claims to CIGNA HealthCare or its designee and wait to receive an
explanation of payment (EOP) before billing the member for any applicable coinsurance and/or
deductible.




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CIGNA HealthCare                                                        Provider Participation
Physician & Health Care
Practitioner Reference Guide


Follow Program Requirements/Administrative Guidelines to receive payment for covered
services. You may not bill for covered services or for services that would have been paid except
for your failure to comply with the provider agreement or Program Requirements/Administrative
Guidelines, including CIGNA HealthCare Utilization Management programs or for billing codes
that are denied due to the application of CIGNA HealthCare standard claim coding and bundling
methodology. This requirement applies following the termination of your provider agreement for
all services provided while the agreement was in effect and supersedes any oral or written
agreement to the contrary between you and the member or persons acting on behalf of the
member.

Confidentiality
CIGNA HealthCare maintains strict policies to protect confidential information. As a participating
practitioner, you are responsible for maintaining the confidentiality of member information in all
settings in accordance with federal and state laws. Written policies and procedures should be
established that include:
• Designation of confidential records
• Control of access to confidential records
• Maintenance of confidential records
• Release of confidential information
If you have questions or comments about CIGNA HealthCare policies, call 1.800.88CIGNA
(882.4462).

Medical Record Reviews
Medical records are used by physicians to plan patient care and provide continuous information
about the patient’s medical treatment. As a permanent record, the patient’s medical record
informs other health care providers about the patient’s medical history.
As part of our quality improvement program, CIGNA HealthCare conducts an Ambulatory
Medical Record Review (AMRR) for physicians in our managed care networks. AMRR
evaluates medical records but does not define standards of care or replace your clinical
judgment.

Medical Record Documentation
To help ensure our members receive effective, safe and confidential patient care, medical
records should be current, detailed and organized. Records should, at a minimum, have these
core elements:
• Updated, complete problem list or summary of health maintenance exams
• Current prescription medication list or medication notes
• Allergies and adverse reactions to medication
• Medical history




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CIGNA HealthCare                                                        Provider Participation
Physician & Health Care
Practitioner Reference Guide


• Visit exam coinciding with chief complaint
• Documentation of treatment plan
• Review of lab and diagnostic studies
• Notation of each follow-up visit
• Consultation report, if requested
• Review of consultant report, if requested
• Follow up on prior problem addressed at each visit
PCPs should ask patients whether they have executed an advance directive declaration (i.e.,
living will or health care power of attorney) and document the response on their medical record.
You must allow CIGNA HealthCare personnel access to members’ medical records for
appropriate CIGNA HealthCare business purposes during normal business hours, including
medical chart review. At the time of service, you must request that members sign a routine
consent form allowing for the disclosures required under the provider agreement and these
Program Requirements/Administrative Guidelines to the extent such consent or authorization is
required by law.
For information on medical record best practices, visit
https://secure.cigna.com/health/provider/medical/quality.html#medrecrev.

Ambulatory Medical Record Review (AMRR)
As part of our Quality Improvement Program, CIGNA HealthCare conducts an annual
Ambulatory Medical Record Review (AMRR). The review assists in quality oversight, but does
not define standards of care or replace the clinical judgment of treating physicians.
The objectives of the AMRR are as follows:
• Determine the structural integrity and retrievability of medical records
• Evaluate the adequacy of information necessary to provide appropriate care to members
• Enhance patient safety by focusing on continuity and coordination of care
• Improve documentation of the clinical care delivered to CIGNA HealthCare members.

CIGNA HealthCare selects a random sample of network primary care physicians/practice sites
with more than 50 members. The sample includes family practice, internal medicine, and
pediatric physicians. Medical records are randomly selected for review from each physician
panel and for members who have been enrolled in CIGNA HealthCare for a minimum of six
months and who have had a minimum of two visits within the last year. Physicians receive a
notification letter from CIGNA HealthCare when they are selected to participate in the review.
The scores of physicians are aggregated, analyzed, and indicators are individually trended. The
goal is an aggregate score of at least 85% compliance among records reviewed. Overall study
results and opportunities for improvement are reported to the Clinical Advisory Committee.
Feedback of AMRR results and areas for improvement are disseminated to primary care
physicians.



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CIGNA HealthCare                                                 Provider Participation
Physician & Health Care
Practitioner Reference Guide

Performance Evaluation
CIGNA HealthCare may provide performance feedback to help you assess and enhance
performance with regard to:
• Quality of care
• Quality of service
• Cost effectiveness

Such performance feedback may be based upon telephone surveys, review of medical records
and analysis of medical utilization. We are available to discuss this feedback.




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CIGNA HealthCare                                                                    Pr
Physician & Health Care                                                 Credentialing
Practitioner Reference Guide


Credentialing
Providers are credentialed prior to joining the CIGNA HealthCare network and periodically
thereafter to ensure they continue to meet CIGNA HealthCare qualifications for participation.
Criteria for participation are determined by CIGNA HealthCare business needs and by our
credentialing/recredentialing policies and procedures, reviewed annually to reflect National
Committee for Quality Assurance (NCQA), local and state standards.
Follow these steps to complete the credentialing process:
1. Call CIGNA at 1.800.88CIGNA (882.4462) to tell us you want to become a participating
   provider.
2. Answer a few quick questions so we can add you to the Council for Affordable Quality
   Healthcare (CAQH) roster and send you a standard contract.
3. Complete and submit the online CAQH application.
4. Sign the contract and return it to CIGNA HealthCare.


Council for Affordable Quality Healthcare (CAQH) Credentialing
Database System
CIGNA HealthCare is part of the Council for Affordable Quality Healthcare (CAQH), a not-for
profit alliance of 53 of the nation’s largest health plans and three trade organizations. CAQH
recognizes the need to simplify administrative requirements and allow you to focus on caring for
patients. Improving processes for obtaining and managing data is a key factor to saving time.
Working with health care providers and various technical and software specialists, CAQH is
sponsoring the Universal Credentialing DataSource initiative.
This sophisticated online database system was developed by member managed care
organizations with help from physicians, professional associations and accreditation
organizations. It allows health care providers to complete one credentialing application and
enter confidential information into one, secure database. With your authorization, this
information is shared with participating health plans and other member organizations. The basic
information is provided only once, and updates are made online or by fax. There is no charge to
submit information to the CAQH credentialing database and providers are contacted regularly to
ensure the information is complete and current.
For more information about Universal Credentialing DataSource or to apply online, visit
www.CAQH.org. For questions about completing the application, call the CAQH Help Desk at
1.888.599.1771 or e-mail CAQH at help@caqh.geoaccess.com.

Submitting Paper Forms
If you don’t have Internet access, call CAQH at 1.888.599.1771 to request a paper application.
In addition, you need to contact Provider Services at 1.800.88CIGNA (882.4462) to initiate the
credentialing and contracting process.




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CIGNA HealthCare                                                                    Credentialing
Physician & Health Care
Practitioner Reference Guide


The credentialing process includes a review of the standard application and independent
verification of certain documentation submitted. Information submitted must be accurate, current
and complete. CIGNA Health Care requirements for physician participating include, but are not
limited to, the following:
• A completed signed and dated application (dated within 90 days). Correction liquid must not
  be used in signature area. Applications with altered signatures will not be processed
• A completed, signed and dated authorization and release form if not included in the
  application form
• A completed, signed and dated physician services agreement (2 originals), copy of a
  completed W-9, and copy of a HCFA-1500 claim form with Box #33 completed
• A current unrestricted license to practice medicine in the state where practicing
• A current unrestricted DEA certificate (if applicable)
• A current unrestricted CDS certificate (if applicable)
• Professional liability insurance with minimum coverage of $200,000 per incident and
  $500,000 aggregate for physicians providing noninvasive services and $500,000 per incident
  and $1 million aggregate for physicians providing invasive procedures
• Acceptable history of professional liability claim experience as determined by CIGNA
  HealthCare
• Completed professional liability form (with explanation of each case). (Not required if
  provided via CAQH application.)
• Acceptable history of Medicare/Medicaid sanctions as determined by CIGNA HealthCare
• Full and valid admitting privileges to at least one CIGNA HealthCare participating hospital.
  Exceptions may be granted in instances where an applicant’s specialty does not typically
  require admitting privileges (e.g., allergy, radiology). Temporary or pending privileges are not
  acceptable.
• Board Certification in a recognized specialty by the American Board of Medical Specialties
  (ABMS), American Osteopathic Association, American Board of Podiatric Surgery or
  American Board of Podiatric Orthopedics and Primary Podiatric Medicine Specialties
• Acceptable responses to all questions on the credentialing application form as determined by
  CIGNA HealthCare

You have certain rights during the credentialing process, including the right to:
• Review information submitted to support your application, including information from outside
  sources
• Correct erroneous information if credentialing information obtained from other sources varies
  substantially from what you provided
• Be informed of the status of your credentialing or recredentialing application.

The decision to accept or deny participation will be communicated in writing.




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CIGNA HealthCare                                                                 Credentialing
Physician & Health Care
Practitioner Reference Guide




Credentialing Criteria Verified Through Office Site Visit
For PCPs and OB/GYNs, the following criteria must be verified through an office site visit by a
CIGNA provider representative:
• Adequate physician coverage and accessibility to members:
• Appropriate arrangements for 24-hour on-call coverage for emergencies
• Scheduled office hours of at least 24 hours per week
• Routine appointment booking of not more than five patients per hour; six patients per hour
  for pediatric offices
• An office that:
   - Is clean and presentable
   - Has adequate waiting room space with comfortable seating for at least five people per
     physician; ten seats per physician for pediatric offices
   - Has at least two exam rooms per physician that are well lighted and provide privacy for
     patients, with examination equipment (otoscope, ophthalmoscope, blood pressure cuff,
     scale) readily accessible
   - Has easy access to a clean, properly supplied bathroom
• Has support staff who are helpful and display a sense of professionalism and helpfulness
• Medical records that meet CIGNA HealthCare standards for organization and completeness.

CIGNA HealthCare will evaluate exceptions to certain of its credentialing criteria on a case-by-
case basis.

Notice of Material Changes
As a participating provider, you are responsible for notifying CIGNA HealthCare immediately of
any material changes to the information presented as part of the credentialing or recredentialing
process. Failure to notify CIGNA HealthCare of changes or to satisfy requirements may result in
your removal from the CIGNA HealthCare network.

Termination Appeal Process
You may appeal a decision by CIGNA HealthCare to terminate your participation in the CIGNA
HealthCare network. Appeals must be submitted in writing within 30 days of notification of
termination from the network. Refer to your provider agreement and the dispute resolution
sections of this reference guide.




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CIGNA HealthCare                                                                    Credentialing
Physician & Health Care
Practitioner Reference Guide



Recredentialing Process
If you participate in the CIGNA HealthCare network, you are recredentialed at least once every
three years or more often if required by state law. If you have not applied through CAQH
Universal Credentialing DataSource, you will be mailed a recredentialing letter approximately six
months prior to your recredentialing date. The letter will direct you to complete the CAQH
Universal DataSource credentialing form.
If you previously completed the CAQH application and have authorized CIGNA HealthCare to
receive current credentialing information, you must update the attestation, update any
information that has changed and submit current supporting documents. If you use a state-
mandated form outside of CAQH, you must update any information that has changed, sign the
attestation and submit the application along with current supporting documents.
During the recredentialing process, completed applications are reviewed and certain new
information is independently verified. The criteria reviewed include but are not limited to:
• Original signature and date of signature (can be done through the CAQH Universal
  Credentialing Data Source application)
• Written explanation relevant to professional liability and practice review questions
• Unrestricted admitting privileges at the CIGNA HealthCare participating hospital indicated on
  the application, as well as date of appointment, scope of privileges, restrictions and
  recommendations
• Current, unrestricted state medical license from a state medical board
• Acceptable professional liability history
• Status of current board certification
• Record of adequate education and board certification for new specialty(ies) in which you
  request to be credentialed
• Professional liability face sheet to ensure professional liability coverage meets CIGNA
  HealthCare requirements
• Medicare/Medicaid sanction report
• Current DEA certificate number (if applicable)
• Current CDS certificate number (if applicable)
• A query and results from the National Practitioner Data Bank

You must not make any material misrepresentations in the information provided during your
contractual relationship with CIGNA, including medical record information. And you must
continue to satisfy the criteria referenced above that were applied at your initial credentialing.
The following documents must be current in the CAQH Universal Credentialing DataSource
system or be submitted in a recredentialing packet. If any of the following documents are
missing, your file cannot be processed, and participation in the CIGNA HealthCare network may
be terminated.




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CIGNA HealthCare                                                                 Credentialing
Physician & Health Care
Practitioner Reference Guide


• Signed, dated and completed professional liability form (Form A) (not required if submitted
  through CAQH)
• Copy of current DEA and CDS (if applicable) certificates
• Copy of current professional liability face sheet

Non-Physician Practitioners
CIGNA HealthCare currently credentials and recredentials non-physician practitioners in the
following categories:
• Certified Midwives and Certified Nurse Midwives
• Certified Registered Nurse Anesthetists
• Licensed Mental and Behavioral Health Workers
• Non-physician Acupuncturists
• Nurse Practitioners
• Occupational Therapists
• Physician Assistants
• Physical Therapists
• Speech Therapists

This list is subject to change and state law mandates. Credentialing and recredentialing
requirements are similar to physician requirements.




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CIGNA HealthCare                                                                            Pr
Physician & Health Care                                Claims and Compensation
Practitioner Reference Guide


Claims and Compensation
Timely and accurate reimbursement is important to you and CIGNA HealthCare. CIGNA
HealthCare has a number of customer service and claim centers throughout the country
responsible for processing claims. For some members, claims processing may be provided by a
third party in accordance with CIGNA standards. The customer service and claim center is
shown on the member’s ID card. You should check the member’s ID card at each visit to
confirm the most current customer service and claim center address.

Claim Submission
You can help improve claim processing accuracy and timeliness by following certain guidelines.
Be consistent when identifying yourself in claim submissions. Using abbreviations or variations
of names or doing business as (DBA) names with combinations of provider licensure numbers
and tax identification numbers not listed in the provider agreement can delay or result in
incorrect claim payments. Notify CIGNA HealthCare in advance of changes to your information.
CIGNA HealthCare strongly encourages participating providers to submit claims electronically.
See the Electronic Services section of this guide for more information.

Paper Claim Submission
Electronic filing is the most efficient method for submitting claims. In those instances where a
provider submits paper claims, CIGNA HealthCare will scan, sort and store paper claims
electronically, in an effort to reduce manual keying errors and improve response time. Providers
can help by adhering to the following guidelines when completing and submitting paper claims:
Use machine-generated, pre-printed red versions of the CMS 1500 claim form, or successor
form, or a copy of the form downloaded from www.cigna.com.
If using a superbill or form other than CMS 1500, the form must have the same information
fields listed as follow in the Definition of a Complete Claim Section.
• Use black ink.
• Provide your National Provider Identifier (if available)
• Make sure all appropriate claim form fields are completed.
• Refer to patient’s CIGNA HealthCare ID card to ensure member ID number/suffix and claim
  submission address is correct.
• Include patient’s CIGNA HealthCare ID number on all claim attachments and
  correspondence.




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CIGNA HealthCare                                                  Claims and Compensation
Physician & Health Care
Practitioner Reference Guide



Definition of a Complete Claim
CIGNA HealthCare defines a complete claim as a claim that can be processed by CIGNA
HealthCare or its designee without additional information from the provider or a third party. The
claim must include:
• Patient name and address
• Patient CIGNA HealthCare ID Number (all digits and suffix)
• Patient date of birth and sex
• Patient relationship to subscriber
• Subscriber name and address
• Subscriber ID number and date of birth
• Subscriber group number
• Patient/subscriber authorization signature
• Provider name, address and telephone number
• Provider tax ID number and CIGNA HealthCare provider number
• Diagnosis Codes (ICD-9, DRG)
• Date of current illness
• First date of same or similar illness
• Date of service
• Location of service
• Standard code sets (CPT-4, Revenue Code, HCPC, NDC)
• Description of procedure(s)
• Billed charge or amount for each procedure
• Other insurance information
• Name of referring physician
• Referral/authorization number
• Admit/discharge date and time
• Admitting/attending physician
• Other or secondary insurance information

NOTE: Any state law, HIPAA Transaction and Code Set requirements or plan-specific language
inconsistent with the CIGNA HealthCare standard Program Requirements/Administrative
Guidelines will supersede these guidelines in the event of a conflict.




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CIGNA HealthCare                                                 Claims and Compensation
Physician & Health Care
Practitioner Reference Guide



Supplemental Claim Information
Sometimes it is necessary to include additional information to support a claim or determine
medical necessity. Supplemental documentation should be included to avoid delays in claim
processing.
Following is a sample of claim categories that require supplemental information. A complete, up-
to-date listing is available online at
http://www.cigna.com/health/provider/medical/procedural/claim_processing/clean_claim.html.
(The requirement to provide supplemental claim information is subject to applicable law and, in
the event of a conflict, applicable law will control.)

CLAIM CATEGORY                               SUPPLEMENTAL ATTACHMENT
Air ambulance                                Narrative/transport notes
Anesthesia                                   Time must be specified
Coordination of Benefits (COB)               Copy of primary carrier’s explanation of
                                             payment (EOP) when CIGNA HealthCare is
                                             secondary
Cosmetic or Potentially Cosmetic             Operative report
Procedures
                                             Office notes and treatment plan
                                             History and physical
                                             Photos (if available)
                                             Height/weight
                                             Operative report and treatment results (if
                                             already performed)
                                             (For Blepharoplasty – visual field testing
                                             results)
Experimental, Investigational or Unproven    Operative or physician notes or other clinical
Procedures                                   information
Home Health Care                             Office notes and treatment plan
                                             All visit notes, complete history and physical
                                             Infusion drug report, if applicable
Modifiers:                                   Operative or physician notes or other clinical
                                             information
22 – Unusual Procedural Services
23 – Unusual Anesthesia
53 – Discontinued Procedures




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CLAIM CATEGORY                                  SUPPLEMENTAL ATTACHMENT
59 – Distinct Procedural Service
62 – Two surgeons
Morbid Obesity                                  Complete history and physical
                                                Proposed treatment plan, including any
                                                surgical procedures
                                                Measures tried previously and patient’s
                                                response
Pre-determinations                              Office notes and treatment plan
                                                Complete history and physical
                                                Photographs, if applicable
Prosthetic Devices                              Invoice
Provider Stop Loss (Facility only)              Itemization by date of service and revenue
                                                code may be needed depending on the type
                                                of stop loss provision
Unexpected Place of Service (i.e., office       Operative or physician notes or other clinical
services performed in an ASC, etc.)             information
Unlisted CPT Codes (i.e., codes ending in       Operative or physician notes or other clinical
99, such as CPT Code 64999 – Unlisted           information
procedure, nervous system)



Claim Filing Deadline
Claims should be filed as soon as possible to ensure prompt payment. CIGNA HealthCare only
will consider hospital or ancillary provider claims submitted within 180 days of the date of
service, subject to the terms of the provider agreement and exceptions noted below.
For services rendered on consecutive days, such as for a hospital confinement, the filing limit
will be counted from the last date of service.
The following are current exceptions to the 180-day time limit:
• Applicable law provides for a longer timely filing limit in which case that time limit will apply
• Coordination of benefits (180-day filing limit is applied based on the primary carrier’s
  processing date as stated on an explanation of benefit or payment)
• Medicare (180-day filing limit is applied based on the primary carrier’s processing date as
  stated on an explanation of benefit or payment)
• Medicare secondary payer (three years)
• Medicaid (two years)




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• Resubmission of a claim originally filed in a timely manner, returned with new or additional
  requested information (180-day filing limit is reset to date of the CIGNA HealthCare request
  for more information)
• Services provided to CIGNA HealthCare members through arrangements with third-party
  vendors (filing limit is applied based on third-party requirements, which may be less than 180
  days)
• Extenuating circumstances such as catastrophic events, etc.

Claim Inquiry and Follow-Up
You can inquire about claim and/or payment status through our website or by telephone. The
explanation of payment will provide the appropriate CIGNA HealthCare representative to
contact for assistance. When contacting us, have the following information available:
• Provider name
• Provider participation number
• Provider TIN
• Member name
• Member ID
• Subscriber name
• Date of service
• Description of service
• Amount of claim
• Date claim was submitted

Payment Policies
Payments under the provider agreement are subject to CIGNA HealthCare’s Payment Policies.
These policies are the guidelines adopted by CIGNA HealthCare for calculating payment of
claims and include CIGNA HealthCare’s standard claim coding and bundling methodology and
claims processing policies and procedures. This guide contains some information about CIGNA
HealthCare’s Payment policies. Contact us for additional information.

Surgical Assistant Modifiers
When a surgery involves an assistant, surgical assistant modifiers apply. Allowed amounts are
based upon your contractual agreement with CIGNA HealthCare.




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Modifier    Definition                               Reimbursement Policy*

       80   Assistant surgeon                        20% of allowed amount for non-
                                                     assisted procedure

       81   Minimum assistant surgeon                10% of allowed amount for non-
                                                     assisted procedure

       82   Assistant surgeon (when qualified        20% of allowed amount for non-
            resident is not available)               assisted procedure

    AS      Physician assistant, nurse practitioner 10% of allowed amount for non-
            or clinical nurse specialist for        assisted procedure
            assistant at surgery


*Note: If the primary procedure requires an assistant, additional covered procedures performed
by the assistant will be reimbursed, subject to the CIGNA HealthCare multiple procedure policy
and your provider agreement.

Multiple Surgery Policy
Multiple surgery reduction guidelines apply to bilateral procedures requiring a separate incision
performed during the same operative session (modifier 50). This policy does not apply to
facilities or procedures deemed to be modifier 51 exempt.

Tips
• Assistant surgeon fees are subject to the multiple procedure policy.
• Participating physicians cannot balance-bill members for charges in excess of CIGNA
  HealthCare allowable amounts.
• In some cases, an office visit is not separately reimbursable from the surgical code so the
  office visit co-payment does not apply.

Immunization Policy
Immunizations and vaccinations for the prevention of diseases are covered under CIGNA
HealthCare standard benefit plans.




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ClaimCheck®
CIGNA HealthCare uses the software known as ClaimCheck® to help implement its standard
claim coding and bundling methodology. This clinically based software system uses rules-based
logic to:
• assess provider claims information including CPT/HCPCS procedure codes against a series
  of edits to detect coding irregularities, conflicts or errors;
• recommend CPT/HCPCS procedure code combinations and request additional claims
  information; and
• reflect CIGNA HealthCare coding guidelines, reimbursement methodologies and coverage
  policy.

This claim editing software is updated twice each year to stay current with changes in the
medical field and coding in particular. With each update, CIGNA HealthCare's Clinical Resource
Unit, Medical Directors and National Contracting staff perform a review of the software to ensure
compliance with our coding guidelines, reimbursement methodologies and coverage policies. A
more detailed summary of ClaimCheck® is available at www.cignaforhcp.com through this link
https://secure.cigna.com/health/provider/medical/pc_0014_claim_editing.html.

Member Liability Collection Guidelines
CIGNA HealthCare offers a variety of health plans with member copayment, coinsurance and/or
deductible requirements. Copayment and deductible plans require members to pay a fixed
dollar amount, while coinsurance plans require members to pay a percentage of the contracted
reimbursement rate.
Collect copayments at the time of service. For patients with plans that require coinsurance
and/or deductibles, you are required to submit claims to CIGNA HealthCare or its designee and
receive an explanation of payment (EOP) indicating the patients’ responsibility before billing
patients for their portion of expenses.
You cannot bill members for covered services or services for which payment was denied due to
your failure to comply with your provider contract or these Program
Requirements/Administrative Guidelines, including CIGNA HealthCare utilization management
requirements and timely filing requirements.

Coordination of Benefits
CIGNA HealthCare members may be covered by more than one health insurance plan. In some
cases, payment may be the primary responsibility of other payers. Billing multiple health
insurance plans to obtain payment is called coordination of benefits (COB). You should assist
CIGNA HealthCare to maximize recoveries under COB and bill services to the responsible
primary plan. After receiving a payment or denial notice from the primary plan, providers should
submit the claim along with a copy of the explanation of payment to CIGNA HealthCare for
consideration of any balance.




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CIGNA as Primary Payer
When the CIGNA HealthCare plan is primary payer, payment is made in accordance with your
agreement with CIGNA HealthCare without regard to the secondary plan. After receiving
payment from CIGNA HealthCare, submit the claim and a copy of the EOP to the secondary
plan.

CIGNA as Secondary Payer
When the CIGNA HealthCare plan is secondary payer, first submit the claim to the primary plan.
After receiving a payment or denial notice from the primary plan, submit the claim to CIGNA
HealthCare, along with a copy of the primary plan EOP. Paper copies are not required from
providers who submit HIPAA-compliant COB content electronically through an EDI claims
submission.
Payment will be no greater than that amount which, when added to the amount payable from
other sources under the applicable COB rules, equals 100% of your reimbursement for covered
services under your provider agreement.

Order of Benefit Determination
CIGNA HealthCare follows the National Association of Insurance Commissioners’ (NAIC)
guidelines regarding the industry standard of order of benefit determination subject to applicable
law and the terms of the benefit plan.

Determining Primacy on a Participant/Spouse
The plan that covers a person as an employee, subscriber or retiree is always considered the
primary payer over a plan that covers the person as a spouse or dependent. If a CIGNA
HealthCare subscriber has two employers and has group health insurance coverage through
both, the plan for the subscriber who has worked longer for the company is considered primary.
If a person has coverage under a state or federal continuation plan and also is covered under
another group health insurance plan, the plan covering the person as an employee, subscriber
or retiree (or as that person’s dependent) is primary and the continuation coverage is
secondary.

Determining Primacy on a Dependent Child
Dependent children of parents who are married and living together follow the “birthday rule.”
The plan of the parent whose birthday falls earlier in the calendar year is primary to the plan of
the parent whose birthday falls later in the year. Only the month and day of birth are relevant;
birth year is not taken into consideration. If both parents have the same birthday, the parent with
the plan that has been in effect longer is primary.
Dependent children of parents, who are divorced, separated or not living together follow the
“custodial rule.” If a court decree states that one of the parents is responsible for the dependent
child’s health care coverage, that parent’s plan is primary, followed by the plan of the other
parent. If a court decree awards joint custody without specifying which parent is liable for
providing health insurance coverage, the birthday rule is followed.




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If there is no court decree allocating responsibility for the dependent’s health coverage, the
order of benefit determination under the custodial rule is as follows:
1.     The plan of the custodial parent
2.     The plan of the custodial parent’s spouse, if applicable
3.     The plan of the non-custodial parent
4.     The plan of the non-custodial parent’s spouse, if applicable

Determining Primacy with Medicare
For Medicare beneficiaries, the order of benefit determination is determined by federal law or
regulation, which may differ from the rules described above. The group health plan that covers
Medicare beneficiaries, age 65 or older, through active employment (theirs or that of their
spouse) and where the employer has 20 or more employees, is the primary payer.
The group health plan is primary for Medicare beneficiaries who have end-stage renal disease
(ESRD) during the first 30 months of their Medicare eligibility.

Workers’ Compensation
Providers must submit a potential workers’ compensation claim to an appropriate workers’
compensation office for review prior to submitting the claim to CIGNA HealthCare. If the
workers’ compensation carrier denies the claim, a copy of the denial must be included with the
claim submission to CIGNA HealthCare. If the workers’ compensation denial is not received with
the claim, payment for services will be denied.
Part of the post-review process may include a CIGNA HealthCare vendor contacting the
member for information about the case. If it is determined that CIGNA HealthCare has made
payment on a valid workers’ compensation case, CIGNA HealthCare will require a full refund.
The CIGNA HealthCare vendor will provide information about that process. Then, resubmit the
claim to the workers’ compensation carrier responsible for payment.

Subrogation/Reimbursement Requirements
Subrogation may apply if a member is injured in an accident of any type and someone else is
responsible for the injury. If you treat a member with a subrogation claim, the provider contract
and these Program Requirements/Administrative Guidelines apply to the same extent they
apply to any other member. Appropriate authorizations must be obtained to ensure payment,
and claims should be submitted to CIGNA HealthCare.




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Payment Recovery
If you receive an overpayment or an otherwise incorrect or inadvertent payment from CIGNA
HealthCare or its designee, a refund to the payer is required. Send the refund and a copy of the
associated explanation of payment to:
               CIGNA HealthCare
               Attn: COR Unit
               PO Box 5725
               Scranton PA 18505-5725

CIGNA HealthCare contracts with several vendors for payment recoveries, such as coordination
of benefits, subrogation and workers’ compensation. These vendors are authorized to contact
CIGNA HealthCare participating providers to request and accept refunds on our behalf. You will
be advised when an overpayment has been identified and will be allowed 30-days’ notice to
refund the excess funds. Our standard recovery method is via refund check from the overpaid
provider. However, CIGNA HealthCare or its designee may deduct the excess payment from
other prospective payments.

Explanation of Payment
The CIGNA HealthCare Explanation of Payment (EOP) itemizes in detail services processed or
considered for payment. CIGNA HealthCare uses a standard format for payment explanations,
combining the check and claim detail information. The information necessary to reconcile a
patient’s account with the CIGNA HealthCare payment is provided in a single document. This
consolidated format is called the “Check/EOP.”

Posting Payments and Adjustments
In addition to posting applicable payments, you are required to make contractual adjustments to
reconcile a patient’s account based upon the CIGNA HealthCare contractual or negotiated rate,
and as noted on the EOP. Contractual adjustments are reflected on the EOP or other CIGNA
HealthCare remittance or payment statement.

Health Care Fraud
Health care fraud is an intentional deception or misrepresentation that a party makes knowing
that the misrepresentation could result in some unauthorized benefit to a member, participating
provider, or other entity or party. Health care fraud increases the cost of health coverage and
creates a loss of public confidence.
CIGNA HealthCare has established an anti-fraud program to help prevent and detect health
care fraud. If there is a reason to suspect a member, a participating provider, a CIGNA
HealthCare employee or some other entity or party of perpetrating health care fraud, call the
CIGNA HealthCare anti-fraud hotline at 1.800.667.7145.




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Electronic Services
CIGNA HealthCare is committed to providing electronic services that make it easier to work with
us.

Quick Summary of Key Tools
TOOL                                         DESCRIPTION
CIGNA for HealthCare Professionals           You can access eligibility, benefit and claim data,
website --                                   forms, precertification information, policies and
                                             procedures and more.
www.cignaforhcp.com


Electronic Data Interchange                  Clearinghouse and direct electronic transactions
                                             for batch claims submission or payment
                                             remittance advice receipts and real-time,
                                             interactive transaction requests for eligibility,
                                             benefit, claim data and precertification.
Electronic Transaction Support Options       Vendor support options for direct or middleman
                                             transactions, including software applications and
                                             clearinghouse alternatives.
1.800 88CIGNA (882.4462)                     Automated telephone system providing access to
                                             eligibility, benefit and claim data and
                                             precertification information, credentialing status,
                                             and more.
Electronic Funds Transfer                    Direct deposit of claim payments to your bank
                                             account.




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CIGNA for Health Care Professionals Website
The CIGNA for Health Care Professionals website allows you to do business with us at your
convenience. Simply log in to www.cignaforhcp.com. There are no costs or fees to use this
service.
Providing real-time, secure information, you can:
• view claim status for claims received but not processed
• conduct an eligibility inquiry for as many as 10 patients at one time
• request fee schedule information for up to 25 codes at one time or a range of codes in a
  given specialty (available to health care practitioners only)
• view claim processing information
• search for patients and claims using a variety of criteria
• view additional benefit details
• find the claim submission address for a patient.
• check patient liability after a claim is processed
• request a copy of your contract
• Download forms
• View CIGNA HealthCare policies and procedures
• E-mail specific questions about claim coding, fee schedules, covered services and coverage
  criteria.

To register and begin using the CIGNA for Health Care Professionals website:
1.   Go to www.cignaforhcp.com
2.   Click on ‘Register Now!’ link (or try our online demo)
3.   Select the category of provider
4.   Follow the automated registration process

You will receive limited access initially and then a registration confirmation letter that gives you
and your staff full access to the website.




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Electronic Data Interchange
Electronic Data Interchange (EDI) includes the following clearinghouse-supported transactions.
(A clearinghouse is a liaison between you and CIGNA HealthCare and provides services,
problem resolution and reports associated with the transactions.)
• Electronic batch claims submission
• Electronic Remittance Advice (ERA)
• Interactive EDI transactions

Electronic Claims Submission
EDI clearinghouses enable you to electronically submit batch claims and receive error-prompt
messages that help ensure claim filing accuracy and completeness. Submitting electronic
claims can help reduce paperwork, time and costs associated with printing and mailing paper
claims.

Electronic Remittance Advice
Electronic Remittance Advice (ERA) is the electronic equivalent of the Explanation of Payment
(EOP). An ERA provides remittance information for adjudicated claims. If you select this service,
you will receive an ERA from CIGNA HealthCare through your claims clearinghouse. The ERA
statement may include electronic and paper claim transactions processed by CIGNA
HealthCare, depending on the type of activity.
If you have enhanced practice management software, you may receive a direct or automatic
download of ERA transactions.
For more information or to apply for ERA services, contact your clearinghouse. The
clearinghouse will send the completed form to the CIGNA HealthCare Provider Data
Organization (PDO) for processing. The PDO will complete the registration within ten days, and
you may begin receiving an ERA on the next payment cycle.

Interactive Electronic Data Interchange Transactions
Interactive Electronic Data Interchange (EDI) transactions are real-time transactions that allow
you to organize and submit information requests. You may use a clearinghouse to submit
individual or bulk inquiries to CIGNA HealthCare at any time and have the option of waiting a
few seconds for the reply or checking back later.
Interactive EDI transactions allow you to obtain eligibility, benefit and claim status information,
and submit precertification requests. In addition, some provider practice management systems
may support direct or automatic transaction downloads.




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Electronic Transaction Support Options*
You have two electronic options for submitting batch claims and exchanging interactive EDI
transactions with CIGNA HealthCare. You may connect directly to CIGNA HealthCare systems
using Post-N-Track software or indirectly by using a clearinghouse as your representative or
middleman.

Post-N-Track
Post-N-Track is a Web-based service that allows you to submit claims directly to and receive
ERA from CIGNA HealthCare. Post-N-Track software is offered free to CIGNA HealthCare
participating providers. The interactive EDI transactions are also available via Post-N-Track. If
you are interested in this cost-effective alternative to paying clearinghouse transaction fees,
contact Post-N-Track at 1.860.632.0572 or by sending an e-mail to enrollme@post-n-track.com.

Clearinghouses
Using a clearinghouse is a common solution to submitting electronic claims and inquiry
transactions to CIGNA HealthCare. If you do not have an existing relationship with a
clearinghouse, you can contact Emdeon (formerly called WebMD) at 1.877.469.3263 or at
www.webmdenvoy.com.
*Please note the Health Insurance Portability and Accountability Act (HIPAA) governs the format
and data content of all electronic transactions.




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1.800.88CIGNA (882.4462)
CIGNA HealthCare offers you instant access to          IVR User Tips
eligibility, benefit and claim information using a
touch-tone telephone by calling                          • Press “*” to repeat
1.800.88CIGNA (882.4462). You may use our                  information just heard
Interactive Voice Response System anytime or
                                                           or repeat menu
speak to a provider services representative
Monday through Friday 8 a.m. to 6 p.m.                     options.
You can receive eligibility and benefit
                                                         • During menu options,
information for multiple members during a
single phone call regardless of plan. When                 press “9” to go back
using the IVR, you have the option of hearing              to the main menu.
the requested information or having it returned
in writing via fax.                                      • After listening to the
You also may submit requests for                           self-service
precertification, referrals and/or prescription            information (such as
authorizations. Detailed claim information is
available, such as claim status, payee, check
                                                           eligibility, benefits,
amounts, and when and where payments were                  claim status), press
sent.                                                      “0” to speak with a
                                                           CIGNA HealthCare
                                                           representative.

                                                         • Press “#” after
                                                           entering data values
                                                           (e.g., member
                                                           identification number
                                                           or DOB).




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Electronic Funds Transfer (Direct Deposit)
Electronic Funds Transfer (EFT) is a direct deposit service available as a claim payment option.
Payments usually post to your designated bank account within 24 hours after claim payment is
released. Direct deposit payment transfers generally occur three times a month according to a
predefined calendar. If you elect this direct deposit option, you should have access to funds on
the same day the electronic transfer is completed. In addition you will receive a Direct Deposit
Activity report in the mail with transaction detail, including information necessary to identify the
claim payment and applicable payment adjustments. It is the equivalent of an Explanation of
Payment (EOP).

Direct Deposit Enrollment Instructions
Use the form accessible through the link that follows for enrollment, cancellation of a service, or
a change. If changes are made to bank account information (e.g., financial institution or a new
account number), another application must be filed with CIGNA HealthCare.
1.   To ensure clear, readable copies, please type or print all requested information.
2.   Provider name: is the facility’s full name. This name must match the legal entity
     associated with the tax identification number (TIN). Only one authorization form should be
     completed per TIN.
3.   Tax identification number is the nine-digit number associated with the legal entity.
4.   For the provider’s billing address, include street, city, state and zip code.
5.   Contact name is the name of the individual to contact with questions about this form.
6.   Telephone number is the number for the contact name.
7.   A voided check for the account(s) must be included with this authorization form.
     A deposit ticket is not acceptable.
8.   Funds can be electronically credited to any commercial account if the financial institution
     is a member of an automated clearinghouse (ACH). Confirm this with your bank.




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9.   Bank Account Information:
     Bank account number to direct deposits
     Bank transit/routing number – The nine-digit number that identifies your bank, usually
     found in the lower left corner of your check. Verify this number with your bank.
     Bank account name – provider, group or business name associated with the bank
     account.
     Bank name – full name of your financial institution (e.g., Your Bank, NA).
     Address – street address, city, state and zip code for your bank.
10. Sign and date the form.
11. Retain a copy for your records. Send the original signed copy with a voided check or MICR
    sheet to:
               CIGNA Corporation
               Direct Deposit Unit, C-328
               900 Cottage Grove Road
               Hartford, CT 06152-1328

You can access a copy of the form through the following link
http://www.cigna.com/health/provider/medical/procedural/reimbursement/so_0001_eraeft_direct
deposit.html.




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Practitioner Reference Guide                  Medical/Utilization Management


Medical/Utilization Management
The CIGNA HealthCare Medical Management Program includes a variety of utilization and
quality management programs that foster communications and make health care resources
available to our members.
The Utilization Management Program is a comprehensive program that incorporates
prospective, concurrent and retrospective reviews, health information and case management
services. The program evaluates continuity and coordination of care and reviews utilization
information for trends and improvement opportunities.
CIGNA HealthCare uses nationally recognized guidelines, reviewed by the CIGNA HealthCare
Quality Committee, including Milliman USA Guidelines for admission, length-of-stay and
continued-stay coverage criteria. Coverage for services is reviewed on a case-by-case basis.
Copies of the clinical coverage guidelines and references applied by CIGNA healthcare are
available at www.cignaforhcp.com or by calling 1.800.88CIGNA (882.4462).
Utilization management decisions are based on appropriateness of care and services as
determined by CIGNA HealthCare clinical coverage guidelines, specific benefit language,
member eligibility, terms of the provider contract and individual circumstances. A physician
reviewer is available to discuss utilization management issues and determinations. This process
referred to as the peer-to-peer review process, gives you the opportunity to provide additional
clinical information. A previous utilization management decision may be revised by a physician
reviewer. If a peer-to-peer review does not result in an augmented payment decision, you may
request an appeal through the CIGNA HealthCare appeal process. CIGNA HealthCare does not
specifically reward practitioners or other individuals for issuing denials of coverage or use
financial incentives that encourage utilization management decisions that result in
underutilization.

Medical Management Models*
An employer can choose from two medical management models regardless of the type of plan.
These two medical management models are called Personal Health SolutionsSM (PHS) and
Personal Health Solutions PlusSM (PHS+).
PHS requires precertification of coverage primarily for inpatient care, while PHS+ requires
precertification of coverage for both inpatient care and certain outpatient services. In addition,
continued stay review begins earlier for members with PHS+. Additional details are outlined as
follows.
*Does not apply to provider groups to which CIGNA HealthCare or an employer group has
delegated responsibility for utilization management. If you participate with CIGNA HealthCare
through a delegated arrangement, continue to follow the delegate’s processes. Some employer
groups have customized medical management options with requirements that vary from the
requirements described in this section.




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Personal Health Solutions (PHS)
• Precertification of coverage is required primarily for inpatient care, including observation,
  rehabilitation, skilled nursing facilities and long term care facilities.
• Continued Stay Review/Inpatient Case Management – Requests for precertification of
  coverage for inpatient admission and length-of-stay will be administered consistent with
  CIGNA HealthCare coverage guidelines (currently Milliman Care Guidelines). Inpatient case
  management will generally begin on the approved Milliman Care Guideline length of stay
  plus one day, or as indicated by the diagnosis, for members still in the inpatient setting. To
  promote consistency, on-site nurses will provide inpatient case management for all
  members. In addition, our members have access to specialized catastrophic and neonatal
  case management programs.
• Clinical Effectiveness Program – Through member and physician education, outreach and
  intervention, this program encourages members to make healthier choices, receive
  preventive screenings and seek appropriate treatment.

Personal Health Solutions Plus (PHS+) (includes PHS provisions outlined above)
• Precertification of coverage is required for both inpatient care and certain outpatient services
  for all medical plans.
• Continued Stay Review/Inpatient Case Management generally begins the first day of
  hospitalization.


Precertification
Precertification of coverage is required for certain medical services. You are responsible for
securing precertification when required and payment may be denied for failure to secure a
required precertification.
For services requiring precertification of coverage, you can initiate precertification by faxing or
calling the Member Services number on the member’s ID card. The following information is
required:
• Member name and ID number
• Member date of birth
• Diagnosis including ICD-9-CM
• Description and code for procedure, service or item to be precertified (CPT-4 or HCPC)
• Place of service and level of care (inpatient or outpatient)
• Requesting or referring provider
• Servicing provider, vendor or facility
• Additional insurance coverage (if applicable)
• Date of injury (if applicable)
• Anticipated length of stay for inpatient stays



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• Date of request
• Pertinent medical history and justification for service

CIGNA HealthCare or its designees make coverage determinations in accordance with the
timeframes required under applicable law. To comply with applicable law, you must supply all
information requested to make a precertification determination within the timeframes specified.
Failure to provide information within the timeframes requested may result in nonpayment.
If a request is approved, a precertification number is assigned. Some situations may require a
second precertification number, including:
• Transfer to another facility; or
• Transfer from an acute hospital bed to a rehabilitation, skilled nursing facility or inpatient
  hospice bed within the same facility.

Precertification is not a guarantee of payment. Coverage is subject to the terms of a member’s
benefit plan and eligibility on the date of service.

Precertification Protocol
You can verify precertification requirements by calling the telephone number on the CIGNA
HealthCare member ID card.
With the exception of emergency/urgent admissions and pre-qualified maternity stays, all
inpatient admissions (e.g., elective, scheduled and unscheduled admissions and observation
stays) require precertification of coverage. Precertification for medical observation stays are
limited to 23 hours. Other services requiring precertification of coverage include selected
outpatient surgeries, procedures and services. Outpatient surgery rates include all post-
operative care required within the first 23 hours post-procedure, including recovery room care
and observation. Therefore, precertification of coverage is not required for post-operative care,
but is required if a member needs to be admitted as an inpatient.
Notification of urgent and emergent admissions is required the day of admission if the CIGNA
HealthCare location has weekend or after-hours coverage or within 24 hours or the next
business day for remaining locations.
Precertification of coverage is also required for elective admission to other inpatient facilities
such as skilled nursing facilities, inpatient hospices, and rehabilitation centers.
Precertification of coverage determinations are based upon eligibility, the specific benefit
language, the terms of the provider contract, CIGNA HealthCare clinical coverage guidelines
and individual circumstances. Some examples of when payment may be denied include when:
• Services exceed the authorized number of visits and/or extend beyond the treatment period
  precertified
• Inpatient hospital or other health care facility charges for services are incurred due to a
  provider’s delay in treatment or care;




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• Inpatient hospital or other health care facility charges for care could safely be provided in a
  less intensive setting; or
• Services are not covered or otherwise excluded from a member’s benefit plan.

The most current list of services requiring precertification of coverage can be accessed at
www.cignaforhcp.com.

Emergency Services
Precertification of coverage is not required for emergency services. However, emergency
services resulting in a hospital admission must be reported on the day of admission to a
member’s primary care physician where applicable and to CIGNA HealthCare if the CIGNA
HealthCare location has weekend and after-hours coverage or within 24 hours or the next
business day for remaining locations. Emergency department copayments do not apply when a
member is admitted directly from or within 24 hours of a related emergency visit. CIGNA
HealthCare or its designees review coverage for emergency services retrospectively.
You must secure precertification of coverage if continuing or follow-up treatment is required
after emergency services are received or after an emergency admission.

Maternity/Obstetric Admissions
Coverage for maternity/obstetric admissions that result in a length of stay of less than 48 hours
after vaginal deliveries or 96 hours after Cesarean deliveries does not have to be precertified.
These admissions are referred to as “pre-qualified maternity stays.” Precertification of coverage
is required for obstetric admissions that extend beyond 48 hours for vaginal deliveries or 96
hours for Cesarean deliveries.

Outpatient Precertification List
The list of services requiring precertification of coverage is updated from time to time. The most
current list of services requiring precertification can be accessed at www.cignaforhcp.com.
Following is a list of outpatient services that must be precertified under standard benefit plans
as of the date of this guide.
• Acupuncture
• Biofeedback
• Back/Spine
• Cochlear implants
• Cosmetic procedures
• Dental implants
• Elective MRI, CT and PET scans
• External prosthetic appliances (some codes)
• Home health care/Hospice – when provided by a fee-for-service or discount provider
• Home infusion therapy, when provided by a fee-for-service or discount provider



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• Hysterectomy
• Infertility treatment
• Injectable medications
• Insulin pumps
• Observation stays, excluding false labor for undelivered obstetric patients
• Orthognathic procedures
• Orthotics
• Penile implants
• Procedures to treat injury to sound natural teeth
• Pulmonary and cardiac rehabilitation, prior to the first visit
• Speech therapy, prior to the first visit when provided by a fee-for-service or discount provider
• TMJ Temporomandibular joint syndrome procedures
• Uvulopalatopharyngoplasty
• Varicose veins treatment

Precertification is not a guarantee of payment. Codes may be considered incidental or mutually
exclusive when billed with other services.

CPT Codes and HCPCS Codes Requiring Precertification
For the most current list of CPT codes and HCPCS codes requiring precertification of coverage,
visit www.cignaforhcp.com.

Physician Office Laboratory Tests
CIGNA HealthCare maintains a list of laboratory procedures that may be performed in a
physician’s office and billed to CIGNA HealthCare. All other laboratory procedures must
bereferred to CIGNA HealthCare-contracted laboratories. Call 1.800.88CIGNA (882.4462) to
determine if a specific lab test is covered under your contract.

Inpatient Case Management/Continued Stay Review
Under the CIGNA HealthCare inpatient case management/continued stay review program,
CIGNA HealthCare or its designee’s nurses or physicians review coverage for a member’s
hospital stay and facilitate discharge planning and post-hospitalization follow-up. You must
provide CIGNA HealthCare or its designee access to information, including:
• Medical records documenting a member’s clinical status and a treatment plan consistent with
  continued inpatient care
• Documentation that a member’s condition cannot be managed safely at another level of care
  (e.g., skilled nursing facility, outpatient, home, etc.), if applicable
• Discharge planning documentation




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Case Management
CIGNA HealthCare Case Management Programs help coordinate care for patients at risk of
developing medical complexities, who have a health incident that requires rehabilitation or
additional support, or who may otherwise benefit from the assistance of a case manager.
Following is an outline of our case management programs. For more information or to refer a
patient, call 1.800.88CIGNA (882.4462) and follow the prompts.

Case Management Program                     Case Manager’s Role
Inpatient and Rehabilitation                Case manager will assist with discharge
                                            planning, including assisting in the
                                            coordination of home health care or
                                            facilitating placement/transfer to extended
                                            care facilities. In addition, there will be post
                                            discharge follow up to help ensure services
                                            ordered by the treating physician are in place
                                            and the patient has filled prescriptions and
                                            understands care directions.
High Risk Maternity                         Case manager will educate members on risk
                                            factors for, and symptoms of, preterm labor
                                            and assist in coordinating home or outpatient
                                            services as appropriate. Case manager will
                                            assist physicians in accessing services to
                                            prevent delivery complications.
Oncology                                    Case manager will help facilitate easy access
                                            to colony-stimulating factors and anti-emetics,
                                            where medically indicated as determined by
                                            the treating physician. Case manager will
                                            assist in the coordination of home or
                                            outpatient services. Education around
                                            benefits to assist with any hospice or other
                                            end-of-life care issues will be provided as
                                            appropriate.


NeoNatal ICU                                Case managers will assist parents with long-
                                            term care planning. Case managers will
                                            assist physicians and families in accessing
                                            home care services. Follow-up case
                                            management post discharge is designed to
                                            help the family prevent emergencies.
Transplant Case Management.                 This program gives the patient and physician
                                            one CIGNA HealthCare point of contact from




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Case Management Program                         Case Manager’s Role
                                                the point of transplant approval through one-
                                                year post transplant to assist in the
                                                coordination of all aspects of care.
Total Joint Recovery Program                    This enhanced program is designed to assist
                                                in the coordination of care before and after
                                                surgery and includes a preoperative home
                                                physical therapy assessment.



Total Joint Recovery Program
Our enhanced preoperative and post discharge total joint recovery program is designed to
assist in the coordination of care for patients before and after surgery and help you with certain
logistical issues related to care.
Upon precertification of coverage for total joint surgery, CIGNA HealthCare assigns a dedicated
hip/knee case manager who contacts and supports the patient. With physician approval, a
CIGNA case manager coordinates a home physical therapy assessment visit preoperatively for
gait training, hip or knee precautions, home safety, and evaluation of durable medical
equipment needs. The physical therapist instructs family members or others who will assist
when the patient returns home. This assessment helps facilitate the transition to a home setting,
benefiting the patient and offering a proactive approach to discharge planning.
The hip/knee case manager coordinates inpatient care with a CIGNA HealthCare inpatient case
manager who works with the treating physician and hospital discharge planner as the
appropriate level of care upon discharge and coverage is determined. While most patients can
return home for post-discharge care, in rare circumstances, patients may require a skilled level
of rehabilitation first. Coverage for a transfer to an acute inpatient rehabilitation setting must be
precertified by CIGNA HealthCare.

Referral Guidelines
For those members covered by plans that require referrals, referrals are made through the
primary care physician (PCP). The PCP must:
• Provide a referral for all specialty care services.
• Send written documentation of a referral to the specialty care provider. Referrals can be sent
  by mail or fax and may be written on a prescription or other form.

PCPs do not need to notify CIGNA HealthCare of a referral to an in-network provider, but should
retain documentation in the patient’s medical record.




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The specialty care provider must
• Communicate with the PCP as appropriate regarding diagnosis, treatment or follow-up care.
• Contact the PCP if he/she does not receive a written referral to obtain one.
• File written referral documentation in the patient’s record. Referral documentation must
  include:
   - Name of PCP
   - Name of specialty care provider to whom the patient was referred
   - Reason for referral
   - Limitations on referral (if applicable)

OB/GYN physicians should continue to notify CIGNA HealthCare upon diagnosis of pregnancy
to initiate enrollment in the CIGNA HealthCare Healthy Babies® prenatal education and support
program. CIGNA HealthCare will continue to monitor compliance with the referral requirement
through the routine medical record review process for PCPs and random and targeted audits of
specialty care providers’ medical records to ensure referrals are documented.
Coverage for services that require precertification, including referrals to out-of-network
providers, must be authorized by CIGNA HealthCare.

Referral Process
When an in-network referral to a participating specialist, hospital (including emergency
services), or ancillary facility is necessary, this is the process:
• A PCP selects a provider from a list of participating providers. If a member has a preference,
  the PCP may accommodate that preference.
• A member referral is usually initiated during an office visit by a PCP based upon medical
  necessity. Approval is subject to member eligibility and benefits at the time of visit.
• The referral provider will examine and treat the member (as authorized by the PCP) and
  document recommendations and treatment. The referral provider will keep the PCP informed
  of findings and treatment plan.
• The referral provider submits a bill to a CIGNA HealthCare claim service center (see the
  specialty networks section if applicable).
• If the referral provider determines the member needs to see another provider, the PCP must
  generate a new referral. For emergency situations, the referral provider may call CIGNA
  HealthCare if the PCP is unavailable.
• The PCP coordinates all other services.

Exceptions To Referral Process
Provider groups for which CIGNA HealthCare has delegated utilization management
responsibility should continue to follow their administrative requirements.




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Open Access, Open Access Plus and PPO
Members with Open Access, Open Access Plus and PPO plans do not need a referral to see a
specialist.

Obstetric and Gynecology (OB/GYN) Care
Although female members may visit their PCP for an annual well-woman exam, they also may
self-refer to a participating OB/GYN for OB/GYN care and to a participating radiologist for a
yearly mammogram.

Mental Health and Substance Abuse Program
CIGNA HealthCare mental health and substance abuse services are generally provided through
CIGNA Behavioral Health, Inc. However, contact Member Services and check the member’s ID
card to verify coverage as some employers have elected other providers for these benefits.
Members eligible for CIGNA Behavioral Health benefits may call the Member Services number
on their CIGNA HealthCare ID card. A mental health coordinator will assess the situation and
determine appropriate service options under the member’s benefit plan. A referral is not needed
for routine outpatient mental health or substance abuse services.

Vision Care
Some members have direct access to routine vision care with participating vision providers and
do not require referrals. Contact Member Services to verify coverage.

CIGNA Well Aware for Better HealthSM
CIGNA Well Aware for Better HealthSM is our approach to care support for patients with chronic
health conditions. Developed in cooperation with participating physicians based on their needs
and experiences, the program provides valuable tools designed to help facilitate the delivery of
quality care.
The program provides individualized education and support for patients with the following
chronic conditions:
• asthma
• diabetes
• heart disease
• low back pain
• chronic obstructive pulmonary disease
• high risk obesity (available 1/1/06)
• depression (available 1/1/06)

In addition, effective 1/1/06, the program will provide education and support for the following ten
targeted medical conditions:
• Acid-related disorders
• Atrial fibrillation




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• Decubitus ulcer
• Fibromyalgia
• Hepatitis C
• Inflammatory bowel disease
• Irritable Bowel Syndrome
• Osteoarthritis
• Osteoporosis
• Urinary incontinence

CIGNA HealthCare identifies members who may benefit from the Well Aware program and
sends program materials to members and physicians.
When your patients participate in the Well Aware program, you receive:
• Well Aware care guides based on national clinical practice guidelines
• Quarterly condition-specific newsletters
• Patient-specific medication reports
• Patient-specific compliance reports twice a year
• Patient-specific notification of positive depression screening (with patient’s permission)
• Information on recognizing depression in patients with chronic conditions
• Other patient-specific information, as appropriate

To access copies or sample some of these tools online, visit www.cigna.com.




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Quality Management
The CIGNA HealthCare Quality Management Program coordinates quality improvement and
quality management activities across all CIGNA HealthCare departments, including Utilization
Management, Contracting and Provider Services, Member Services, and Claims.
The Quality Management Program outlines processes for measuring quality and provides
guidance in initiating process improvement initiatives when deficiencies are identified. Quality
measurement studies are designed to evaluate the quality and appropriateness of care and
service provided to members, using the following activities:
• Review performance against the key quality indicators as identified in the quality work plan.
• Evaluate member and provider satisfaction information.

CIGNA HealthCare uses the Continuous Quality Improvement (CQI) Process, a problem-solving
approach, when an opportunity for improvement has been identified through an evaluation of
performance indicators or from other sources. If you would like more information about our
Quality Management Program, including more description of the program and a report on
CIGNA's progress in meeting its goals, call 1.800.88CIGNA (882.4462).
CIGNA HealthCare encourages input from providers by inviting them to actively participate in
several of our quality committees, including the Quality Management Committee, the Peer
Review Committee and the Credentialing Committee. Our commitment to quality is
demonstrated through the program activities described as follows.

Clinical Care Guidelines
Clinical care guidelines can be used as a resource as you screen and treat various conditions
and include the following guidelines:
• Preventive health guidelines, including pediatric, adult, prenatal and postpartum
• Clinical guidelines for behavioral health, including depression, attention-deficit/hyperactivity
  disorder and alcohol screening
• Well Aware Care Guides for disease management, including high-risk obesity, depression,
  asthma, diabetes, cardiovascular disorders, low back pain, chronic obstructive pulmonary
  disease and other targeted conditions

For the alcohol screening guidelines, visit www.cignabehavioral.com and choose “Are You a
Provider?” For our other latest guidelines, visit
www.cigna.com/health/provider/medical/care_guidelines.html. You can also call 1.800.88CIGNA
(882.4462) to request a paper copy of the guidelines.




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Peer Review
Peer review is used to help uncover substandard or inappropriate care or inappropriate
professional behavior by a practitioner. If the findings of the confidential peer review process
indicate substandard or inappropriate patient care or inappropriate professional conduct, CIGNA
HealthCare will exercise its discretion and take appropriate. The actions that may be taken
include development of a corrective action plan, education, counseling, monitoring and trending
of data, recredentialing within one year or a shorter period of time, notification to appropriate
state and/or federal bodies, and limitation of or termination from participation. Peer review
information is generally considered privileged and confidential under applicable state and
federal laws.

Medical and Behavioral Continuity and Coordination of Care
CIGNA HealthCare monitors continuity and coordination of care across health care network
settings and transitions in those settings. Examples of this occur when:
• A practitioner treats the same patient as an organizational provider across different settings,
  such as outpatient to inpatient and back to outpatient
• There is a change in management of care among practitioners (primary care to specialist or
  specialist to primary care)
• A practitioner becomes active or inactive during ongoing care
• A practitioner leaves the network or a member completes a continued access period as
  defined by medical management policy.

Assessment of continuity and coordination of care may include committee discussions, medical
record reviews, and data analysis.
CIGNA HealthCare, in collaboration with CIGNA Behavioral Health, reviews continuity and
coordination of behavioral care through assessment of:
• Diagnosis, treatment and referral of common behavioral health disorders
• Use of psychopharmacological medications
• Management of treatment access and follow up for members with medical and behavioral
  health disorders
• Implementation of a primary or secondary behavioral health preventive program
• Encouragement of members to allow behavioral health practitioner to share information with
  PCP




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Pharmacy and Therapeutics Review
CIGNA HealthCare national pharmacy and therapeutics review is performed by the Pharmacy
and Therapeutics Committee, which develops and maintains the formulary. Committee
members include local practicing physicians, clinical pharmacists, CIGNA HealthCare medical
and pharmacy directors, and outside pharmacology consultants. The committee meets quarterly
to examine the safety and efficacy of new drugs.
The drug evaluation process employed by the Pharmacy and Therapeutics Committee is an
evidence-based approach to clinical literature. A comprehensive drug monograph is prepared
by an external university-based drug information service and presented to the committee.
Through the Pharmacy and Therapeutics Committee evaluation process, drugs are identified for
inclusion in the formulary. The committee considers how well each drug works and potential
side effects. Prior to market introduction, the committee evaluates new drugs to determine if
they offer a therapeutic benefit over existing formulary drugs. New drugs shown to be effective
and safe, but not possessing a unique clinical advantage, may be selected based on cost.

Clinical and Quality Improvement Studies
Clinical and quality improvement studies are designed to evaluate quality and appropriateness
of care provided to members. Topics for routine evaluation and for special studies are chosen
based on relevant demographics and epidemiological characteristics of plan membership.
Clinical studies review issues such as preventive care/HEDIS measures against preventive care
guidelines and compliance with treatment standards for depression. Scientifically based criteria
are used for specific conditions, as developed by nationally recognized organizations and
adopted by CIGNA HealthCare. Population-based assessment is conducted whenever
appropriate, supplemented by focused medical record review and/or patient surveys. Data are
collected, reviewed and analyzed for trends and opportunities for improvement.

Provider Excellence Recognition Directory
The CIGNA HealthCare Provider Excellence Recognition Directory publicly recognizes
participating physicians who have achieved recognition from the National Committee for Quality
Assurance (NCQA) for diabetes and/or heart and stroke care. The recognition directory also
includes participating hospitals that fully meet one or more of the Leapfrog patient safety
standards.
To access the directory, visit http://cigna.benefitnation.net/cignams/default.asp.




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Health Plan Employer Data and Information Set (HEDIS®)
Health Plan Employer Data and Information Set (HEDIS®) measures are standardized
performance measures developed and maintained by the National Committee for Quality
Assurance (NCQA), a not-for-profit organization committed to assessing, reporting on and
improving the quality of care provided by managed care organizations. HEDIS is designed to
help ensure purchasers and consumers have the information they need to reliably compare the
performance of managed health care plans. HEDIS also includes the Consumer Assessment
Healthplan Study (CAHPS), a standardized survey of consumer experiences that evaluates plan
performance in areas such as member service, access to care and claims processing. Individual
HEDIS measures also may be used to evaluate the efficacy of health management systems, the
impact of practice guidelines, and adherence to preventive health recommendations.
CIGNA HealthCare annually compiles preventive and chronic health data according to HEDIS
guidelines. The data collection process occurs from February through May of each year and is
obtained from claim and encounter data administrative systems. However, to help capture an
accurate and comprehensive reflection of the care provided to members, CIGNA HealthCare
also audits a sampling of medical records for some measures. The records for HEDIS are
requested and received by mail and by scheduled on-site visits from trained HEDIS medical
record review nurses. Your cooperation is essential to the success of the HEDIS program.
A CIGNA HealthCare representative contacts your office to arrange the review process. Once
the on-site review is scheduled, you receive a list of member names and the measures selected
for the review process. If the list consists of a few members, you may be asked to mail or fax the
required information. During the review, CIGNA HealthCare will copy only those portions of
selected medical records that include relevant information.
Participants in the review are selected through a random sampling process as stringently
outlined by NCQA. All identifying information is kept confidential. Your provider agreement
provides for the release of medical record information to CIGNA HealthCare for these quality
projects. Contact the local Provider Relations representative or review the guidelines on the
HIPAA website at http://www.cms.hhs.gov/hipaa/ if you have questions or concerns.

HEDIS Medical Record Review
The following standards are part of the record documentation and review process.
• HEDIS review auditors require copies of the actual medical record.
• Time frames are very specific. Requested records are for the prior year or earlier.
• Member names should appear clearly on both sides of the documentation.
• Complete dates (mm/dd/yy) should be on each entry.
• Names of other specialists, physicians and/or facilities that treat patients should be
  documented.
• The immunization history should be included. Request a copy of the school vaccine
  administration record and/or a copy of the previous PCP immunization history.
• For breast, cervical and colorectal cancer screening, document the date when the diagnostic
  procedure was performed and the results. Obtain the actual diagnostic reports for your
  records.

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• For patient being monitored due to hypertension, document the diagnosis of hypertension in
  the patient medical history and/or in the problem list.
• For beta blocker treatment after a heart attack, the standard of care is to prescribe a beta
  blocker within one-week after an acute myocardial infarction. A copy of the hospital
  discharge summary or a copy of a progress note indicating the start date of beta blocker
  treatment is needed.
• Obtain all ophthalmologist or optometrist reports for dilated retinal exams for patients with
  diabetes. Include the actual lab results in the medical record.
• For pediatric well-care visits, document dates of well-care visit(s) and physicals and any
  evidence of ongoing issues.

2006 HEDIS® Measures for 2005 Data
HEDIS or the Health Plan Employer Data and Information Set is a core set of approximately 70
performance measures developed by the National Committee on Quality Assurance (NCQA) in
collaboration with employers and health plans. The following are the detailed performance
standards for key measures.



A.     Childhood Immunization Status

The percentage of enrolled children 2 years of age who had four DtaP/DT, three IPV, one
MMR, three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four
pneumococcal conjugate vaccines by their second birthday. The measure calculates a
rate for each vaccine and two separate combination rates.
Note: Combo 1 retired In HEDIS 2006

Combination 2: Children who received four Combination 3: Children who received all
DtaP/DT vaccinations; three IPV           antigens listed in combination 2 and four
vaccinations; one MMR vaccination; three  pneumococcal conjugate vaccinations.
HiB vaccinations; three hepatitis B
vaccinations; and one VZV vaccination.

Eligible Population:
Enrolled children turning two in the measurement year who were continuously enrolled for
one year prior to their second birthday.




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B.     Adolescent Immunization Status

The percentage of enrolled adolescents 13 years of age who had a second dose of MMR, three
hepatitis B and one chicken pox (VZV) by their 13th birthday. The measure calculates a rate for
each vaccine and one combination rate.

Combination 1: Retired in HEDIS 2006.        Combination 2: Adolescents who received the
                                             second MMR; three hepatitis B vaccinations; and
                                             one VZV.

Eligible Population:
Enrolled Adolescents turning 13 in the measurement year who were continuously enrolled for
one year prior to their 13th birthday.



C.     Cervical Cancer Screening

The percentage of women 18–64 years of age who received one or more Pap tests during the
measurement year or the two years prior to the measurement year.

Eligible Population:
Women 21–64 years old as of December 31 of the measurement year who were continuously
enrolled for the measurement year and the two years prior to the measurement year.



D.     Chlamydia Screening in Women

The percentage of women 16–25 years of age who were identified as sexually active that had
at least one test for chlamydia during the measurement year. This measure is expressed as
three rates:

Rate 1: 16-20 year old women                 Rate 3: Overall rate (ages 16-25)

Rate 2: 21-25 year old women

Eligible Population:
Women 16–25 years old as of December 31 of the measurement year who are sexually active
and were continuously enrolled for the measurement year.




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E.     Breast Cancer Screening

The percentage of women ages 50 through 69 who had a mammogram during the
measurement year or the year prior to the measurement year.

Eligible Population:
Women 52–69 years old as of December 31 of the measurement year who were continuously
enrolled for the measurement year and the year prior to the measurement year.



F.     Colorectal Cancer Screening

The percentage of adults 50–80 years of age who had appropriate screening for colorectal
cancer (CRC).

Eligible Population
Members 51–80 years old as of December 31 of the measurement year who were continuously
enrolled during the measurement year and the year prior to the measurement year.



G.     Prenatal and Postpartum Care

The measure assesses the following aspects of care:

Rate 1: Timeliness of Prenatal Care: The      Rate 2: Postpartum Care: The percentage of
percentage of women that received a           women that had a postpartum visit on or between
prenatal care visit as a member of the plan   21 and 56 days after delivery.
in the first trimester or within 42 days of
enrollment in the plan.

Eligible Population:
Women who delivered a live birth between November 6 of the year prior to the measurement
year and November 5 of the measurement year and who were continuously enrolled at least 43
days prior to delivery through 56 days after delivery.




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H.     Use of Appropriate Medications for People with Asthma

The percentage of eligible population who were appropriately prescribed medication during the
measurement year. The measure is expressed as four rates:

Rate 1: 5-9 year olds                        Rate 3: 18-56 year olds

Rate 2: 10-17 year olds                      Rate 4: Overall total (5-56 years old)

Eligible Population:
Members 5–56 years old by December 31 of the measurement year who were continuously
enrolled for the measurement year and the year prior to the measurement year and were
identified as having persistent asthma during both the measurement year and the year prior to
the measurement year.



I.     Beta Blocker Treatment After a Heart Attack

The percentage of eligible population who received an ambulatory prescription for beta-
blockers upon discharge.

Eligible Population:
Members 35 years and older as of December 31 of the measurement year, who were
continuously enrolled on the discharge date and seven days after discharge and were
hospitalized and discharged alive from January 1 – December 24 of the measurement year with
a diagnosis of acute myocardial infarction (AMI).



J.     Persistence of Beta Blocker Treatment After a Heart Attack

The percentage of eligible population who received persistent beta-blocker treatment for six
months after discharge.

Eligible Population:
Members 35 years and older as of December 31 of the measurement year, who were
continuously enrolled on the discharge date and 180 days after discharge and who were
hospitalized and discharged alive from July 1 of the year prior to the measurement year to
 June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI).




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K.     Cholesterol Management After Acute Cardiovascular Event

The percentage of eligible population, who had each of the following during the measurement
year:

Rate 1: LDL-C screening                      Rate 3: LDL-C level of <100 mg/

Rate 2: LCL-C level of <130 mg/dL

Eligible Population:
Members 18-75 years as of December 31 of the measurement year, who were continuously
enrolled during the measurement year and the year prior to the measurement year and who,
from January 1 through November 1 of the year prior to the measurement year were
discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic
Vascular Disease (IVD).



L.     Comprehensive Diabetes Care

Percentage of member compliant with the seven rates for this measure:

Rate 1: Hemoglobin A1c (HbA1c) testing       Rate 5: LDL-C controlled (LDL <130 mg/dL)

Rate 2: HbA1c poorly controlled (>9.0%)      Rate 6: LDL-C controlled (LDL <100mg/dL)

Rate 3: Eye exam (retinal) performed         Rate 7: Kidney disease (nephropathy) monitored

Rate 4: LDL-C screening performed

Eligible Population:
Members with Diabetes (type 1 and type 2) 18 through 75 years as of December 31 of the
measurement year who were continuously enrolled during the measurement year. Diabetics
are identified via pharmacy and claims/encounter data.




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CIGNA HealthCare                                                        Quality Management
Physician & Health Care
Practitioner Reference Guide



M.     Controlling High Blood Pressure

The percentage of eligible population whose blood pressure (BP) was adequately controlled
(<=140/90) during the measurement year.

Eligible Population:
Members 46-85 years with a diagnosis of hypertension (HTN) as of December 31 of the
measurement year who were continuously enrolled during the measurement year. A member
is considered to be hypertensive if there is at least one outpatient encounter with an ICD-9
diagnosis code of 401 during the first six months of the measurement year.



N.     Antidepressant Medication Management

This measure assesses different facets of the successful pharmacological management of
depression and has three components:

Rate 1: Optimal Practitioner Contacts for     Rate 2: Effective Acute Phase Treatment: The
Medication Management: The percentage         percentage of members who remained on an
of members who had at least three follow-up   anti-depressant drug during the entire 84-day
contacts with a non-mental health             (12-week) Acute Treatment Phase
practitioner or mental health practitioner
during the 84-day (12-week) Acute             Rate 3: Effective Continuation Phase: The
Treatment Phase. At lease one of the three    percentage of members who remained on an
follow-up contacts must be with a             anti-depressant drug for at least 180 days (6
prescribing practitioner.                     months)

Members 18 years and older as of April 30 of the measurement year who were diagnosed with
a new episode of major depressive disorder, from May 1 of the year prior to the measurement
year and ending on April 30 of the measurement year and treated with antidepressant
medication, who were continuously enrolled 120 days prior to the diagnosis of major
depression through 245 days after the diagnosis.




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CIGNA HealthCare                                                        Quality Management
Physician & Health Care
Practitioner Reference Guide



O.     Follow-Up After Hospitalization for Mental Illness

There are two rates for this measure:

Rate 1: The percentage of members who         Rate 2: The percentage of members who had an
had an ambulatory follow-up encounter with    ambulatory follow-up encounter with a mental
a mental health practitioner on the date of   health practitioner on the date of discharge, up to
discharge, up to 30 days after hospital       7 days after hospital discharge.
discharge.

Eligible Population:
Members with mental health benefits ages six and older as of the hospital discharge date that
were continuously enrolled for 30 days after discharge from an inpatient setting of an acute
care facility with a discharge date occurring on or before December 1 of the measurement year
with a principal ICD-9-CM diagnosis code indicating mental health disorder from a specified
list.



P.     Medical Assistance with Smoking Cessation

This measure assesses different facets of providing medical assistance with smoking
cessation:

Rate 1: Advising Smokers to Quit:             Rate 3: Discussing Smoking Cessation
                                              Strategies:
Percentage of eligible members who
received advice to quit smoking.              Percentage of eligible members whose
                                              practitioner recommended or discussed smoking
                                              cessation methods or strategies.

Rate 2: Discussing Smoking Cessation
Medications:
Percentage of eligible members whose
practitioner recommended or discussed
smoking cessation medications.

Members 18 years of age and older who were continuously enrolled during the measurement
year, who were either current smokers or recent quitters, and who were seen by a practitioner
during the measurement year.




801759 TriState Physician                      94
CIGNA HealthCare                                                        Quality Management
Physician & Health Care
Practitioner Reference Guide



Q.     Appropriate Treatment for Children with Upper Respiratory Infection

The percentage of children 3 months to 18 years of age who were given a diagnosis of upper
respiratory infection (URI) and were not dispensed an antibiotic prescription on or 3 days after
the Episode Date. This process measure assesses if antibiotics were inappropriately prescribed
for children with URI.

Eligible Population:
Children age 3 months as of July 1 of the year prior to the measurement year to 18 years as of
June 30 of the measurement year who were continuously enrolled 30 days prior to the Episode
Date through 3 days after the Episode Date.



R.     Appropriate Testing for Children with Pharyngitis

The percentage of children 2–18 years of age who were diagnosed with pharyngitis, prescribed
an antibiotic and who received a group A streptococcus test for the episode. This measure
assesses the adequacy of clinical management of pharyngitis episodes for members who
received an antibiotic prescription.

Eligible Population:
Children age 2 years as of July 1 of the year prior to the measurement year to 18 years as of
June 30 of the measurement year who were continuously enrolled 30 days prior to the Episode
Date to 3 days after the Episode Date.



S.     Use of Imaging Studies for Low Back Pain

The percentage of the eligible population who received imaging studies for evaluating patients
with low back pain. Measure assesses overuse.

Eligible Population:
Members 18-50 as of December 31 of the measurement year with continuous enrollment 180
days prior to the earliest encounter with a primary low back pain diagnosis during the
measurement year




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CIGNA HealthCare                                                         Quality Management
Physician & Health Care
Practitioner Reference Guide


New 2006 HEDIS® Measures

T.     Inappropriate Antibiotic Treatment for Adults With Acute Bronchitis

The percentage of the eligible population who were dispensed an antibiotic prescription on or
within three days after the diagnosis of acute bronchitis. This misuse measure assesses if
antibiotics were inappropriately prescribed for healthy adults, and a lower rate represents better
performance.

Eligible Population:
Adults 18 years as of January 1 of the year prior to the measurement year to 64 years as of
December 31 of the measurement year with an outpatient visit with any diagnosis of acute
bronchitis during January 1 – December 24 of the measurement year.



U.     Use of Spirometry Testing in the Assessment and Diagnosis of COPD

The percentage of the eligible population 40 years and older who received appropriate
spirometry testing to confirm the diagnosis.

Eligible Population:
Members 42 years and older by December 31 of the measurement year who were
continuously enrolled 720 days prior to a new or newly active chronic COPD diagnosis through
180 days after the diagnosis during July 1 of the year prior to the measurement year to June
30 of the measurement year.



V.    Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder
Medication

There are two rates for this measure that assess follow-up care for children prescribed an
ADHD medication:

Rate 1: Initiation Phase: The percentage of     Rate 2: Continuation and Maintenance Phase:
eligible members who had one follow-up          the percentage of eligible members who
visit with a practitioner with prescriptive     remained on the medication for at least 210 days
authority during the 30-day Initiation Phase.   and had at least two additional follow-up visits
                                                with a practitioner within nine months after the
                                                Initiation Phase ends.




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CIGNA HealthCare                                                         Quality Management
Physician & Health Care
Practitioner Reference Guide


Eligible Population:
Rate 1: Children 6-12 years as of the earliest prescription dispensing date for an ADHD
medication where date is during March 1 of the year prior to the measurement year through
February 28 of the measurement year and there is a negative medication history for 120 days
prior to dispensing date. Child must be continuously enrolled for 120 days prior to the earliest
dispensing date and 30 days after the earliest dispensing date.
Rate 2: Children 6-12 years as of the earliest prescription dispensing date for an ADHD
medication where date is during March 1 of the year prior to the measurement year through
February 28 of the measurement year and there is a negative medication history for 120 days
prior to dispensing date. Child must be continuously enrolled from 30 through 300 days after
the earliest dispensing date.



W.     Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis

The percentage of the eligible population who had at least one ambulatory prescription
dispensed for a disease modifying anti-rheumatic drug.

Eligible Population:
Members 18 years and older as of December 31 of the measurement year with continuous
enrollment during the measurement year and with two face-to-face physician encounters with
different dates of service in an ambulatory or nonacute inpatient setting on or between January
1 and November 30 of the measurement year with any diagnosis of rheumatoid arthritis.



X.     Annual Monitoring for Patients on Persistent Medications

Percentage of eligible members who has at least one therapeutic monitoring event for the
therapeutic agent in the measurement year.

Rate 1: ACE Inhibitors or ARBs                Rate 4: Anticonvulsants

Rate 2: Digoxin                               Rate 5: Statins

Rate 3: Diuretics

Eligible Population:
Members 18 years and older as of December 31 of the measurement year with continuous
enrollment during the measurement year and receiving at least a 180-days supply of
ambulatory medication in the measurement year for the following: ACE Inhibitors or ARBs,
Digoxin, Diuretics, Anticonvulsants, or Statins .




801759 TriState Physician                       97
CIGNA HealthCare                                                Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide                           Prescription Drug Program


Prescription Drug Program
CIGNA HealthCare offers a prescription drug benefit program where members generally are
required to purchase prescription drugs from CIGNA HealthCare participating pharmacies or our
mail order pharmacy to be covered. Drugs are supplied per prescription order or refilled in
quantities normally prescribed up to a 30-day supply or as defined by CIGNA HealthCare, the
Federal Drug Administration (FDA) or applicable law. Up to a 90-day supply of maintenance
medication may be dispensed through the mail service prescription drug program.
CIGNA HealthCare requires that generic equivalents be dispensed for brand-name drugs as
available and appropriate in the clinical judgment of a physician. Members who prefer a brand-
name drug rather than its generic equivalent may be subject to a higher co-payment.

Plan Options
Members who have a CIGNA HealthCare pharmacy benefit are enrolled in one of the following
plans:
• Two-tier
• Three-tier
• Four-tier

Members in the two-tier prescription drug plan are covered for prescription drugs included in the
CIGNA HealthCare prescription drug list (PDL) or formulary. Members pay one copayment
amount for generic or first-tier drugs and a slightly higher copayment for preferred brand-name
or second-tier drugs that have no generic equivalent.
Members in the three-tier prescription drug plan have three copayment levels, depending on a
drug’s assigned category on the CIGNA HealthCare prescription drug list or formulary. Generic
or first-tier drugs have the lowest co-payment; preferred brand-named drugs with no generic
equivalent are considered second-tier drugs and have a slightly higher copayment; and drugs in
the third tier have the highest copayment. Third-tier drugs include brand names that have
equally effective and less-costly generic equivalents or have one or more preferred brand-name
options.
Members in the four-tier prescription drug plan have four copayment levels, depending on the
drug’s assigned category on the CIGNA HealthCare prescription drug list or formulary. Generic
or first-tier drugs have the lowest copayment. Preferred brand-named drugs with no generic
equivalent are considered second-tier drugs and have a slightly higher copayment. Drugs in the
third tier include brand names that have equally effective and less-costly generic equivalents or
have one or more preferred brand-name options and are covered at the third tier copayment.
The fourth-tier category consists of either self-administered injectables or therapeutic class
options. There is also a four-tier plan design option that separates preferred brand drugs into
two categories (second and third tier) and moves the non-preferred brand tier three drugs into
the fourth tier.
If you have questions about our Prescription Drug Program, call 1.800.88CIGNA (882.4462).




801759 TriState Physician                      98
CIGNA HealthCare                                                Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide



Prescription Drug List
The Prescription Drug List is a subset of the top drugs and therapeutic classes from the CIGNA
HealthCare formulary. This preferred list of FDA-approved medications is the foundation of the
CIGNA HealthCare prescription drug program. You may access the entire formulary online at
https://secure.cigna.com/health/form/drug_list.html or request a paper copy by calling
1.800.88CIGNA (882.4462).
If a requested prescription drug is not listed in the PDL or formulary and the member has the
two-tier closed formulary benefit, CIGNA HealthCare will review the request as an exception.
Exceptions may include non-formulary drugs, precertification, step therapy, off label and early
refills. You may request an exception by calling the pharmacy exception center at
1.800.CIGNA24 (244.6224).

Medications Requiring Precertification
Participating physicians and participating pharmacies in the CIGNA HealthCare network are
responsible for following the CIGNA HealthCare outpatient drug formulary. If a generic or
formulary drug should not be prescribed in the medical judgment of the prescribing physician, or
due to non-availability, or if the prescribed drug is one of the few medications on the PDL that
require prior approval of coverage, you are required to contact the CIGNA HealthCare
pharmacy service center to request precertification of coverage.
You have several options for submitting precertification requests:
• Fax a completed prescription coverage request to 1.800.390.9745
• E-mail your request to rxazfaxsys@cigna.com
• Call 1.800.832.3211

All information fields must be complete and legible when submitting a request. The review
process may take 48 hours. Incomplete forms will be denied or returned for missing information.
Requests marked as urgent will be reviewed the same day they are received.
A copy of the prescription coverage request form is provided on the following page and is also
available at www.cigna.com.




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CIGNA HealthCare                                                   Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide


                    CIGNA HealthCare Prescription Coverage Request Form

                            View the formulary online at http://www.cigna.com

Notice: Failure to complete this form in its entirety may result in delayed processing or an adverse
determination for insufficient information

Our standard response time for prescription drug coverage requests is 2-4 business days.
If your request is urgent, it is important that you call Pharmacy Services at 800.832.3211 to
expedite the request.

               Physician Information                                 Patient Information


Name:                                                   Name:


                                                        CIGNA HealthCare ID #:
                                                        ___________________________________
        PCP
        Specialist: ___________________________
                                                        DOB:

Office contact name:
                                                        Address:

Facsimile#:
                                                        Phone #:
Phone #:
Address:


Drug Requested                        Dosage                             Strength


Diagnosis (related to use)                              Expected duration of therapy (beginning and
                                                        ending dates)


Have formulary alternatives been tried?
        No
        Yes (if yes, include drug name, length of trial, and any samples given)




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CIGNA HealthCare                                                 Prescription Drug Program,
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Physician Signature                                    Date




     All space below this line is reserved for CIGNA HealthCare Pharmacy Services’ use only

PSA COMMENTS                         RPH COMMENTS                         MD COMMENTS




   INCLUDE INITIALS, DATE &              INCLUDE INITIALS, DATE &             INCLUDE INITIALS,
       CRITERIA REVIEW                       CRITERIA REVIEW                   DATE & CRITERIA
         COMMENTS                              COMMENTS                      REVIEW COMMENTS




Medications Typically Excluded from the Prescription Benefit
Coverage for prescription drugs and related supplies is subject to the terms and conditions of a
member’s benefit plan, including but not limited to the “exclusions and limitations” section of the
benefit plan. The following are typically excluded from the prescription benefit:
1. Any drugs available over the counter that do not require a prescription by federal or state
   law and any drug that has a chemical equivalent to an over-the-counter drug other than
   insulin.
2. Drugs that are therapeutically equivalent as determined by the CIGNA HealthCare
   Pharmacy and Therapeutics Committee available over the counter.
3. Any injectable infertility drugs and any injectable drugs that require physician supervision
   and are not typically considered self-administered drugs.
4. Any drugs that are experimental or investigational within the meaning set forth in the benefit
   plan.
5. Food and Drug Administration (FDA)-approved prescription drugs used for purposes other
   than those approved by the FDA unless the drug is recognized for the treatment of the
   particular indication in one of the standard reference compendia (The United States
   Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or
   The American Hospital Formulary Service Drug Information) or in medical literature. Medical
   literature means scientific studies published in a peer-reviewed national professional
   medical journal.




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CIGNA HealthCare                                                 Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide


6. Any prescription and non-prescription supplies (such as ostomy supplies), devices, and
   appliances.
7. Any contraceptive drugs and prescription appliances for contraception.
8. Implantable contraceptive products.
9. Any fertility drug.
10. Any drugs used for treatment of sexual dysfunction, including but not limited to erectile
    dysfunction, delayed ejaculation, anorgasmia and decreased libido.
11. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride
    products.
12. Drugs used for cosmetic purposes, such as drugs used to reduce wrinkles, drugs to promote
    hair growth, drugs used to control perspiration, and fade cream products.
13. Any diet pills or appetite suppressants (anorectics).
14. Prescription smoking cessation products.
15. Immunization agents, biological products for allergy immunization, biological sera, blood,
    blood plasma and other blood products or fractions, antihemophilic agents and medications
    used for travel prophylaxis.
16. Replacement of prescription drugs and related supplies due to loss or theft.
17. Drugs used to enhance athletic performance.
18. Drugs taken by or administered to a member while the member is a patient in a licensed
    hospital, skilled nursing facility, rest home or similar institution which operates on its
    premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

Prescriptions more than one year after the original date of issue.
The CIGNA Tel-Drug mail order prescription drug program is designed for members with
maintenance medication needs (after a 90-day grace period). Members pay a single mail order
copayment for up to a 90-day supply of maintenance medications* and for each refill allowed by
that order when prescribed by a participating physician in the CIGNA HealthCare network or an
authorized referral physician, unless otherwise required by applicable law. The 90-day-supply
maximum is subject to physician judgment and FDA dosage recommendations. In cases where
a 90-day supply is not recommended by the FDA, prescribing physician, or CIGNA HealthCare,
the mail order quantity will be limited.
A generic equivalent drug automatically will be substituted unless you indicate “dispense as
written.” Members or physicians may contact CIGNA Tel-Drug by calling 800.TELDRUG
(800.835.3784) or by accessing www.teldrug.com.
*Maintenance drugs are prescription drugs used to manage chronic or long-term conditions
when members respond positively to drug treatment and dosage adjustments.




801759 TriState Physician                       102
CIGNA HealthCare                                                  Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide



CIGNA Tel-Drug One Touch
Designed to simplify administrative requirements for you and your office staff, the CIGNA Tel-
Drug One Touch program makes ordering specialty pharmacy medications easy. When calling
or faxing orders to CIGNA Tel-Drug, the pharmacy team will:
•   Verify member eligibility
•   Obtain prior authorization as applicable
•   Bill CIGNA HealthCare directly
•   Provide patient education materials and supplies when requested
•   Coordinate shipping to physician or member


Specialty Pharmacy Prescription Drug Program
You may order injectable medications for CIGNA HealthCare members by contacting CIGNA
Tel-Drug. CIGNA Tel-Drug can provide most specialty pharmacy medications for a variety of
therapeutic classes. Some examples include injectable medications for the treatment of:
• Multiple sclerosis
• Rheumatoid arthritis
• Growth hormone deficiency
• Respiratory syncytial virus
• Endocrine/metabolic conditions
• Blood modification
• Infertility
• Hepatitis C
• Hemophilia

CIGNA Tel-Drug specialty medication prescription orders are shipped confidentially and
delivered by first class mail. Special packaging and overnight delivery of next-day orders and/or
medications requiring refrigeration are also available.
Immunizations and drugs administered intravenously via a home care provider are not offered
through the specialty pharmacy prescription program.

Preferred Specialty Pharmaceutical List*
CIGNA HealthCare recently announced a Preferred Specialty Pharmaceutical List. The decision
of which drugs to prescribe is up to you based on your clinical judgment, and coverage is not
limited to the preferred drug. All of the medications included on the list that follows are available
through CIGNA Tel-Drug Specialty Pharmacy. Access the most current list, information on the
program or download the CIGNA Tel-Drug medication order forms at www.cigna.com. Choose
“Drug Lists/Ordering” under Popular Links.




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CIGNA HealthCare                                                Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide




 Growth Hormones                                 Humatrope®

                                                 Nutropin®

                                                 Nutropin AQ®

                                                 Nutropin Depot®

 Hepatitis C Antivirals                          Pegasys®

 Infertility Agents                              Follistim®

 Multiple Sclerosis Agents                       Betaseron®

                                                 Copaxone®

 Rheumatoid Arthritis Agents                     Humira®

                                                 Remicade®


*CIGNA HealthCare may receive payments from manufacturers regarding the medications
included in the Preferred Specialty Pharmaceutical List. Payments may or may not be shared
with the member’s benefit plan depending on the benefit plan’s arrangement with CIGNA
HealthCare. Depending upon plan design, market conditions, the extent to which manufacturer
payments are shared with the member’s benefit plan, and other factors as of the date of service,
the preferred medication may or may not represent the lowest cost medication within the
therapeutic class for the member and/or the benefit plan. CIGNA HealthCare reserves the right
to make changes to this Preferred Specialty Pharmaceutical List without notice.

Specialty Pharmacy Orders
Physicians should contact CIGNA Tel-Drug Specialty Pharmacy Services for all injectable
medication prescriptions as follows:

New Orders
• Fax a completed general injectable medication fax order form to 1.800.351.3616.
• Telephone injectable medication prescription information to 1.800.351.3606.

Transfers
• Fax a completed general injectable medication fax order form to 1.800.351.3616 and
  indicate which pharmacy currently holds the prescription, including all necessary pharmacy
  contact information.
• Call 1.800.351.3606 and speak with a specialty pharmacy pharmacist to transfer the
  prescription.




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CIGNA HealthCare                                                Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide




A CIGNA Tel-Drug pharmacist will review the order form and will contact CIGNA HealthCare to
request precertification of coverage, when required.

Change in Coverage for Self-administered Injectable Medications
In 2005, CIGNA changed coverage for self-administered injectable medications.* A defined list
of injectable medications are no longer covered under the CIGNA medical plan, but are covered
under the CIGNA Pharmacy Plan. This change applies to specialty pharmacies you and your
patients may use to obtain these medications under a CIGNA medical plan.
Medical plans that have implemented this benefit change will no longer cover the cost of these
medications. To be covered under the CIGNA Pharmacy Plan, these medications must be
obtained either from a retail pharmacy or the CIGNA Tel-Drug Specialty Pharmacy subject to
the terms of the plan. If required, you may continue to administer these medications and you will
be reimbursed for related administration costs. However, medical plans that have implemented
this benefit change will no longer reimburse you for the cost of these medications.
If your patient’s pharmacy benefit is provided by a company other than CIGNA, contact the
pharmacy provider for information about coverage for these medications.
Self-Administered Injectable Medications Covered Under a Standard CIGNA Pharmacy Plan
• Actimmune
• Apokyn
• Avonex
• Betaseron
• Calcimar
• Caverject
• Copaxone
• Edex
• Enbrel
• Forteo
• Fuzeon
• Genotropin
• Humatrope
• Humira
• Infergen
• Kineret
• Miacalcin
• Norditropin
• Nutropin



801759 TriState Physician                      105
CIGNA HealthCare                                               Prescription Drug Program,
Physician & Health Care
Practitioner Reference Guide


• Nutropin AQ
• Nutropin Depot
• Peg Intron
• Pegasys
• Protropin
• Raptiva
• Rebetron
• Rebif
• Roferon-A
• Saizen
• Serostim
• Somavert**
• Supprelin
• Tevtropin
• Xolair

*Does not apply to members covered by a capitated risk group that has accepted responsibility
for injectable medications. Actual coverage is subject to the terms of the particular member’s
benefit plan.
**Medication can be ordered through the Pfizer bridge program by calling 1.800.645.1280.
A general fax order form and medication-specific Tel-Drug injectable fax order form are
available at www.cigna.com by selecting “Important Forms” under Popular Links.




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CIGNA HealthCare                                                         Specialty Networks
Physician & Health Care
Practitioner Reference Guide                                     Specialty Networks



Specialty Networks
CIGNA HealthCare has specialty networks that complement our local provider networks.
Requirements for referral and precertification of coverage under these arrangements may vary
from standard requirements and can be verified by calling Member Services at the telephone
number on the member ID card.
The following specialty networks service the CIGNA HealthCare community. Any state-specific
networks are shown in the Introduction and Important Information section.

CIGNA LIFESOURCE Transplant Network®
The CIGNA LIFESOURCE Transplant Network includes more than 80 of the nation’s leading
medical facilities renowned for their performance in organ and tissue transplantation. This
exclusive network gives our members access to quality care for organ and tissue
transplantation, as well as a commitment to manage complex procedures.
Before including a transplant program in the CIGNA LIFESOURCE Transplant Network, the
program must meet our quality standards for experience, survival rates and transplant team
personnel. CIGNA LIFESOURCE conducts extensive annual reviews to ensure transplant
facilities maintain quality standards.
Members who are organ and/or tissue transplant candidates are assigned specially trained
nurse transplant case managers who coordinate care for candidates and recipients. To contact
the CIGNA LIFESOURCE transplant case management unit, call 1.800.668.9682. Or, for more
information and a list of in-network facilities, visit www.cigna.com/lifesource.

CIGNA Behavioral Health
CIGNA Behavioral Health provides benefits for most CIGNA HealthCare members and offers a
broad range of services that address the behavioral dimensions of health, disability and
workplace productivity. Benefits are managed through Regional Care Centers, whose staff
performs telephone intakes, patient registration, care management, and provider relations
activities. CIGNA Behavioral Health provides access to behavioral health professionals through
a network of independently contracted providers and behavioral health and chemical
dependency facilities.
Through its Care Advocacy Program, CIGNA Behavioral Health members can self-refer to in-
network providers for routine mental health and substance abuse outpatient services. To
arrange or confirm an inpatient referral or psychiatric consultation, contact CIGNA Behavioral
Health at the number on the member’s ID card. Hours of operation for routine business are
Monday through Thursday from 8 a.m. to 7 p.m., and Fridays from 8 a.m. to 5 p.m. Advocates
and care managers are available 24 hours a day for clinical emergencies.
For more information on CIGNA Behavioral Health or to find out who is in the network, visit our
website at www.CIGNABehavioral.com.




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CIGNA HealthCare                                                              Dispute Resolution
Physician & Health Care
Practitioner Reference Guide                                         Dispute Resolution



Dispute Resolution
Following are the requirements necessary for submitting a first- and second-level appeal of a
payment or contract termination decision.

Provider Payment Appeals
CIGNA HealthCare strives to informally resolve issues raised by providers on initial contact
whenever possible. If issues cannot be resolved informally, CIGNA HealthCare offers a two-
level, internal appeal process for resolving contractual disputes regarding post-service payment
denials unless a single level appeal process is required by state law. Following the internal
CIGNA HealthCare process, arbitration may be used as a final resolution step.
The payment appeal process is different from routine requests for follow-up inquiries on claim
processing errors or missing claim information. Most claim issues can be remedied quickly by
providing requested information to a claim service center or contacting us. In the event that a
claim resubmission is unsuccessful, filing an appeal may be warranted.
Please note, if there is a conflict between this reference guide and your provider agreement with
CIGNA HealthCare or applicable law, the terms of your agreement or the applicable law will
supersede this guide.

First-Level Review
To initiate a first-level review, you must submit the following information in writing within 180
calendar days of the date of the initial payment or denial notice or, if the appeal relates to a
payment that was adjusted by CIGNA HealthCare, within 180 calendar days from the date of the
last payment adjustment: Submit one appeal per form
• A completed Provider Payment Appeal form (available at www.cignaforhcp.com)
• A copy of the original claim and EOP or explanation of benefit (EOB), if applicable
• For reviews with a clinical component, such as services denied for no precertification or for
  not being medically necessary, supporting documentation should include a narrative
  describing the situation, an operative report and medical records, as applicable.

After preparing the necessary documentation, visit www.cignaforhcp.com for additional details.
If a decision is made to uphold the initial decision, an appeal-denial letter will be sent to the
provider outlining any additional appeal rights.

Second-Level Review
If you are not satisfied with the resolution of the first-level review, you may submit the appeal to
a second-level review within 60 calendar days of the date of the first-level review determination.
• Repeat steps above, indicating a second-level request on the appeal form or letter.
• Include any additional or pertinent supporting documentation.

Return the completed documentation as directed in the first-level determination notice.



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CIGNA HealthCare                                                             Dispute Resolution
Physician & Health Care
Practitioner Reference Guide


Level two appeals of payment denials based upon failure to satisfy medical necessity
requirements of a member’s plan will involve a review by a specialist in the provider’s field. If
state law requires a single-level appeal process, such review will occur at the single level of
appeal.

Additional Payment Appeal Options
After exhausting the internal appeal process, the following dispute resolution mechanisms may
be available.
For appeals of payment denials based upon medical necessity, there is an option to request
binding external review through an independent review organization, unless a member’s self-
funded employer plan does not include an external review option. Note that such external
review may be available for medical necessity appeals after the level-one appeal if a specialist
in the provider’s field reviewed the level-one appeal and the provider submits a form signed by
the member stating that he or she does not intend to pursue his/her own appeal. Additional
information is available at
http://www.cigna.com/health/provider/medical/procedural/claim_appeals/appeal_policies_proce
dures.html.
For appeals of payment denials relating to claim coding or bundling edits, there may be an
option to request binding external review from the billing dispute administrator. Procedures for
submitting an appeal to a billing dispute administrator are outlined in the level-two appeal denial
letter or at www.cigna.com.
Alternatively, arbitration may serve as a binding, final-resolution step as specified in a provider
agreement and/or Program Requirements/Administrative Guidelines.

Provider Termination Appeals
On occasion, CIGNA HealthCare deems it necessary to terminate a provider’s participation. To
initiate a first-level review of a provider termination, submit the following information in writing
within 30 calendar days of the date of the provider termination notice.
• A completed provider-termination appeal letter indicating the reason for the appeal
• A copy of the original termination notice
• Supporting documentation for reconsideration

Second-Level Review
If you are not satisfied with the resolution of the first-level review, you may submit the appeal to
the second-level review within 60 calendar days of the date of the first-level review
determination as follows:
• Repeat steps above, indicating a second-level request on the appeal form or letter
• Include any additional or pertinent supporting documentation




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CIGNA HealthCare                                                             Dispute Resolution
Physician & Health Care
Practitioner Reference Guide




Arbitration
Payment or termination disputes that are not resolved through first and second-level review
appeals or the additional payment appeal options referenced above and any other disputes
between the parties regarding the performance or interpretation of a provider agreement will be
resolved through arbitration. Either party may initiate arbitration by providing written notice to the
other party. With respect to provider payment or termination disputes, you must request
arbitration within one year of the date of the letter communicating the second-level-review
decision.
If an arbitration provision was placed in your provider agreement, the terms and conditions of
that provision will apply. If your provider agreement does not include an arbitration provision, the
following will apply.
• The proceedings will be held in the jurisdiction of the provider's domicile
• The parties will select a mutually acceptable arbitrator within 30 days
• If the parties cannot agree on an arbitrator, then the parties prepare a Request for a Dispute
  Resolution List and submit it to the American Health Lawyers Association Alternative Dispute
  Resolution Service (AHLA ADR Service) along with the appropriate administration fee. In
  accordance with the Codes of Ethics and Rules of Procedure developed by the AHLA ADR
  Service, the parties will be sent a list of 10 arbitrators along with a background and
  experience description, references and fee schedule for each. The 10 will be chosen by the
  AHLA ADR Service based on their experience in the area of the dispute, geographic location
  and other criteria as indicated on the request form. The parties to the dispute will review the
  qualifications of the 10 suggested arbitrators and rank them in order of preference from 1 to
  9. Each party has the right to strike 1 name from the list. The person with the lowest total will
  be appointed to resolve the case.
• Each party will assume its own costs, but compensation and expenses of the arbitrator(s)
  and any administrative fees or costs will be shared equally by the parties, subject to any
  limitation on fees or costs required under the MDL No. 1334 Settlement Agreement Among
  CIGNA HealthCare and Physicians during the period of time such requirements are in effect
• Arbitration will be the exclusive remedy for disputes arising under the provider agreement
• The decision of the arbitrator(s) will be final, conclusive and binding, and no other recourse
  may be taken by either party other than to enforce the award of the arbitrator(s)
• This resolution procedure is a private undertaking and may not be consolidated with other
  providers or third parties and may not be conducted on a class basis
• Judgment of the arbitrator(s) award may be entered in any court of competent jurisdiction

The provider agreement remains in force during arbitration unless otherwise terminated in
accordance with the terms of the provider agreement
If you do not request a first- or second-level review or arbitration of the dispute within the
defined timeframes, the last CIGNA HealthCare determination will be final. Members cannot be
billed for any amount denied because you failed to submit the request for review or arbitration
within required timelines.


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CIGNA HealthCare                                                           Member Information
Physician & Health Care                                           Member Information
Practitioner Reference Guide



Member Information
CIGNA HealthCare members standardly receive a CIGNA HealthCare identification (ID) card
that includes an identification number, information about designated copayments, coinsurance
and deductibles and the name of the PCP assigned to the member, if applicable. The ID card
does not guarantee eligibility.
Each time members visit your office, request to see an ID card. You can verify eligibility based
on our then current records by:
• Visiting our CIGNA for Health Care Professionals website − www.cignaforhcp.com
  (registration is required)
• Calling 1.800.88CIGNA (882.4462), our automated telephone services
• Calling Member Services (telephone number is shown on the member’s ID card)

If a member does not have an ID card or enrollment form, call 1.800.88CIGNA (882.4462).
CIGNA HealthCare makes no representations or guarantees concerning the number of
members referred to a provider and reserves the right to direct members to selected
participating providers and/or to influence members’ choice of participating provider.


Replacement of Social Security Number by Alternate Member
Identifier
To help protect the privacy of our members and prevent identity theft, CIGNA HealthCare is
phasing out the use of Social Security Numbers (SSN) as the member identifier. As a result,
SSNs of many members will no longer be printed on ID cards or used in member
correspondence.
CIGNA HealthCare began transitioning to a nine-digit CIGNA alternate member identifier in
January 2005. By the end of 2005, this CIGNA alternate member identifier (AMI) will replace the
subscriber SSN on most members’ ID cards.
As CIGNA HealthCare transitions to new identifiers, you may see some ID cards that include
the SSN. Use the identifier on the member’s ID card to submit claims and inquire about eligibility
or claim status. For members with an AMI, CIGNA HealthCare will accept claims and inquiries
submitted with either the AMI or the subscriber SSN.
Please note: Many of the new identifiers begin with U0 (zero). In some cases, when entering
the identification number the capital letter O is being input instead of the number 0 (zero). If your
CIGNA claim submissions are rejected for “invalid ID,” please ensure that you or your staff have
entered the correct identifier – U0 (zero), rather than UO (capital letter O).
In addition, you may submit the subscriber ID with or without the subscriber relationship suffix
as shown on the member ID card (U0123456701).




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CIGNA HealthCare                                                        Member Information
Physician & Health Care
Practitioner Reference Guide




Verification Options
For information on a member’s benefit plan, including copayments, coinsurance or deductible
amounts:
• Review the member’s ID card
• Log in to the CIGNA for Health Care Professionals website at www.cignaforhcp.com
• Call 1.800.88CIGNA (882.4462)
• Call Member Services at the number on the member’s ID card.

Member Rights and Responsibilities
The following statement of member rights and responsibilities is given to CIGNA HealthCare
members when they enroll. This statement, addressed to members, also appears periodically in
member newsletters. While states may mandate variations, the statement typically reads as
follows.
You Have the Right to:
• Receive medical treatment that is available when you need it and is handled in a way that
  respects your privacy and dignity.
• Get the information you need about your health care plan, including information about
  services that are covered, services that are not covered and any costs that you will be
  responsible for paying.
• Have access to a current list of providers in the CIGNA HealthCare network and have
  access to information about a particular provider’s education, training and practice.
• Select a Primary Care Physician (PCP) for yourself and each covered member of your
  family, and change your PCP for any reason.
• Have your medical information kept confidential by CIGNA HealthCare employees and your
  health care provider. Confidentiality laws and professional rules of behavior allow CIGNA
  HealthCare to release medical information only when it’s required for your care, required by
  law, necessary for the administration of your plan or to support CIGNA HealthCare programs
  or operations that evaluate quality and service. We may also summarize information in
  reports that do not identify you or any other members specifically.
• Participate with your practitioner in health decisions and have your health care provider give
  you information about your medical condition and your treatment options, regardless of
  benefits coverage or cost. You have the right to receive this information in terms you
  understand.
• Learn about any care you receive. You should be asked for your consent for all care, unless
  there is an emergency and your life and health are in serious danger.
• Refuse medical care. If you refuse medical care, your health care provider should tell you
  what might happen. We urge you to discuss your concerns about care with your PCP. Your
  doctor will give you advice, but you’ll have the final decision.


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CIGNA HealthCare                                                          Member Information
Physician & Health Care
Practitioner Reference Guide


• Be heard. Our complaint-handling process is designed to: hear and act on your complaint or
  concern about CIGNA HealthCare and/or the quality of care you receive, provide a
  courteous, prompt response and guide you through our grievance process if you do not
  agree with our decision.
• Make recommendations regarding our policies on member rights and responsibilities. If you
  have recommendations, please call Member Services at the toll-free number on your CIGNA
  HealthCare ID card.

You Have the Responsibility to:
• Review and understand the information you receive about your health care plan. Please call
  CIGNA HealthCare Member Services when you have questions or concerns.
• Understand how to use CIGNA HealthCare services.
• Show your CIGNA HealthCare ID card before you receive care.
• Schedule a new patient appointment when you select a new PCP from the CIGNA
  HealthCare network, build a comfortable relationship with your doctor, ask questions about
  things you don’t understand and follow your doctor’s advice. You should understand that
  your condition may not improve and may even get worse if you don’t follow your doctor’s
  advice.
• Understand your health condition and work with your doctor to develop treatment goals that
  you both agree upon to the extent that this is possible.
• Provide honest, complete information to the providers caring for you.
• Know what medicine you take, why and how to take it.
• Pay all co-payments for which you are responsible, at the time service is rendered.
• Keep scheduled appointments and notify the doctor’s office ahead of time if you are going to
  be late or miss an appointment.
• Pay all charges for missed appointments and for services that are not covered by your plan.
• Voice your opinions, concerns or complaints to CIGNA HealthCare Member Services and/or
  your provider.
• Notify your benefits administrator as soon as possible about any changes in family size,
  address phone number or membership status.

Member Concern or Complaint
If members have concerns or complaints about administration, coverage or exclusions in their
benefit plan, or service or care received, they can contact CIGNA HealthCare. An attempt will
be made to resolve the problem during an initial telephone call. If a member is not satisfied with
our response, he/she may follow the member appeals process outlined in his/her benefit plan
document.




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CIGNA HealthCare                                                           Member Information
Physician & Health Care
Practitioner Reference Guide


Provider Cooperation
CIGNA HealthCare may contact you during the review and investigation of a member’s concern,
complaint or appeal and information or written statements may be requested. You are required
to cooperate and assist with the resolution and appeals process within the timeframes
requested to help ensure a fair review and so CIGNA is compliant with applicable laws.
A member may request your assistance with regard to an appeal. We encourage you to assist
the member by providing all relevant clinical records.

Health Insurance Portability and Accountability Act (HIPAA) of 1996
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 law ensures the
portability of insurance coverage to protect individuals from “prior condition” limits due to
changes in employment or coverage.
The Administrative Simplification provisions of HIPAA include regulations about privacy,
standard code sets and transactions, security and unique health identifiers. They were designed
to safeguard an individual’s Protected Health Information (PHI), standardize the transmission of
certain common transactions between health care entities, and standardize the medical codes
used in those transactions. These standardization rules help reduce health care administrative
costs.
We are committed to maintaining the confidentiality of our member’s PHI. We have established
policies and procedures to protect oral, written and electronic PHI. Our Notice of Privacy
Practices describes how we use and disclose PHI and advises members of their rights under
federal and state laws. For a copy of the notice, visit www.cigna.com/general/misc/privacy.html
or call 1.800.88CIGNA (882.4462).
CIGNA HealthCare expects you to be compliant with HIPAA and other applicable confidentiality
laws.

Security Regulations
The HIPAA standards for the security of electronic health information specifies a series of
administrative, technical, and physical security procedures for covered entities to use to ensure
the confidentiality, integrity and availability of electronic protected health information. The
compliance date for covered entities, with the exception of small health plans, was April 21,
2005. Small health plans must comply by April 21, 2006.




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